Anesthesia Coding Alert

Anesthesiologists often use transesophageal echocardiography (TEE) during cardiovascular cases. Some anesthesiologists may not be sure which parts of the service carriers reimburse and exactly what type of documentation you need to code the case properly. Use these expert tips to get your documentation and coding up to par.

Remember: Only report the portion of the service your anesthesiologist provides. "We also add modifier 26 (Professional component)," says Judy A. Wilson, CPC, CPC-H, CPC-P, CPC-I, CPC-ANEST, CMBSI, CMRS, with Anesthesia Specialists in Virginia Beach, Va. Reporting modifier 26 shows that your physician finished the test but does not own the equipment. The anesthesiologist must also provide a written report if he does the TEE, Wilson adds. And the anesthesiologist should be TEE certified, according to many insurance companies.

CPT 2008 includes several codes for TEE, but some apply strictly to cardiologists rather than anesthesiologists. The complete group of TEE codes includes:

• 93312 -- Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report.

Code 93312 may be appropriate for those anesthesiologists who have credentials to perform the entire TEE procedure, interpretation and report.
• 93313 -- ... placement of transesophageal probe only.

Code 93313 doesn't include the TEE interpretation and report. Submit 93313 when your anesthesiologist places the probe but a cardiologist performs the interpretation and report.
• 93314 -- ... image acquisition, interpretation and report only.

Code 93314 coincides with 93313. If your anesthesiologist reports 93313, the cardiologist must report 93314.
• 93315 -- Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report.

You may be able to report this code if your anesthesiologist is credentialed to perform the entire TEE procedure, especially if he concentrates on cardiac anesthesia.

• 93316 -- ... placement of transesophageal probe only
• 93317 -- ... image acquisition, interpretation and report only.

Codes 93316 and 93317 have the same extended descriptors as 93313 and 93314. Choose the correct code based on whether the patient has congenital heart problems.

Take note: Code 93315 is the complete service. You should bill 93316-93317 only if the anesthesiologist didn't provide all services described by 93315.
• 93318 -- Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis.

Your anesthesiologist might report 93318 most often, due to using TEE probes for monitoring.

Red flag: Some carriers do not pay for 93318 because the global anesthesia fee includes monitoring. Because 93318 is not billable during anesthesia, not reporting it may be the safest option -- if a payer such as Medicare does reimburse it, you may have to refund the money or risk a fraud investigation.

Modifier note: Because you can report TEE services in addition to the procedural anesthesia, append modifier 59 (Distinct procedural service) to the TEE code in these cases. Make sure you include a separate diagnosis for Medicare. Do not, however, append modifier 59 to 93318.

Your anesthesiologist will decide to use TEE based on the patient's condition or surgery -- TEE is often used in cardio valvular replacements, for example. "The patient's disease process and possible diagnostic complications are the determining factors as to which patients will benefit from the use of TEEs," says Lorraine Gledhill, CPC, with Lahey Clinic in Burlington, Mass.

Carriers often prefer detailed diagnoses to support TEE's necessity, such as:
• 086.0 -- Chagas' disease with heart involvement
• 394.0 -- Mitral stenosis
• 427.31 -- Atrial fibrillation
• 429.3 -- Cardiomegaly
• 429.71 -- Acquired cardiac septal defect
• 440.0 -- Atherosclerosis; of aorta
• 996.02 -- Mechanical complication of cardiac device, implant, and graft; due to heart valve prosthesis.

Boot up your software: Many coders, including Gledhill, use coding software to help identify which diagnosis codes cross-reference to TEE procedures. Tools like these can offer up to 160 diagnoses to choose from, she adds.

Check your work: However, even if you have cross-referencing software, remember your program might not have all the answers. For example, some carriers accept V15.1 (Other personal history presenting hazards to health; surgery to heart and great vessels) as a diagnosis supporting TEE, and yet Gledhill does not see V15.1 as an option in her software. "But that does not necessarily mean it can't be used," she says. "Always verify the diagnoses with your carrier."

Despite the existence of other monitoring techniques, your anesthesiologist may choose TEE because it provides information regarding surgical interventions, anesthesia effects and the patient's condition that other diagnostic procedures do not. No matter which TEE code you report, your anesthesiologist needs to document the case as thoroughly as possible.

Documentation templates may help physicians adequately document their work. A template might include areas for:
• whether the TEE was for monitoring or diagnostic
• dictation of a thorough report covering the physician's examination and findings
• indications for the TEE exam
• atrial, ventricular and aortic assessments with comments
• postprocedure follow-up
• any complications
• the procedure's recording.

Gledhill's physicians have a dictation template for the TEE documentation, which prompts and guides the anesthesiologist in his documentation. "We also make each physician aware of the proper compliance for submitting TEE codes and stress the possibility of lost revenue if the proper documentation has not been met," she says.

Educate your physicians to submit thorough documentation of their TEE services. That will make most of your claims go through processing without any trouble.