Anesthesia Coding Alert

With quarterly Correct Coding Initiative (CCI) edits changing so many coding guidelines throughout the year, it's easy to miss things that can potentially impact your practice. One example is the group of codes for transesophageal echocardiography (TEE), which anesthesiologists are using more often.

Anesthesiologists commonly place the probe for TEE procedures, which you should code as CPT 93313 (Echocardio-graphy, transesophageal, real time with image documentation [2D] [with or without M-mode recording]; placement of transesophageal probe only) or 93316 (Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only). But many anesthesiologists are training to perform different aspects of TEE procedures, which means you should be familiar with guidelines regarding the other TEE codes.

Some Edits May Be Bypassed

All CCI edits have a "modifier status indicator" that determines whether the edit is absolute (with an indicator of "0") or if it can be overridden by appending a modifier when appropriate (with an indicator of "1"). Some new edit assignments related to TEE coding can make a big difference in correct coding and reimbursement.

In addition to the two codes described above, several other TEE codes are affected by CCI edits. These include:
 

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

93314 image acquisition, interpretation and report only

93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report

93317 image acquisition, interpretation and report only

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.

When CCI first published edits for this group of codes, we heard several different interpretations of what the edits meant. Here are some of the questions we heard, along with clarifications:
 

"Are any edits associated with 93318?" This code has an indicator of 0, which means you cannot use a modifier (such as -59, Distinct procedural service) to unbundle the codes for multiple procedures and bill them separately. "This code cannot be overridden with a modifier, even though many anesthesiologists use this code," says Sharon Ryan, a coder with the physician group Anaesthesia Associates of Massachusetts in Westwood.
 

"Can the edits for 93312, 93313 and 93314 be bypassed (or unbundled) so I can get separate payment for the TEE procedure?" Yes, these codes (and all the other TEE codes except 93318) have a 1 indicator, which means the edit can be bypassed by appending a modifier in appropriate situations. Code 93312 is for probe placement, image acquisition, and written interpretation and report. Meanwhile, 93313 is probe placement only for diagnostic purposes. Code 93314 is for image acquisition and report.
 

"Is it appropriate to append modifier -59 to the TEE codes to unbundled them?" When the anesthesia provider performs TEE for monitoring purposes, CCI bundles it into the anesthesia code (after all, monitoring is what anesthesiologists do when providing anesthesia). But, as Ryan notes, if TEE is for diagnostic purposes, then it is a separate and distinct service and should be unbundled by appending modifier -59.
 

"Can the ASA code for monitoring be overridden?" The reader is probably referring to code 93318, which is used for monitoring purposes. It does have a 0 indicator, which means it cannot be overridden, as noted above.

Look at Physician Involvement

So, considering these 0 and 1 indicator edits, how should different TEE scenarios be coded, depending on the anesthesiologist's involvement in the procedure? Basically the same as in the past.

If an anesthesiologist only places the TEE probe, code with 93313-59.
 

If one anesthesiologist places the probe and provides anesthesia for the procedure, and another anesthesiologist (who has appropriate training) performs the procedure, code with 93314 for the physician performing the procedure and interpreting results, and code 93313-59 for the physician placing the probe and providing anesthesia.
 

If the anesthesiologist provides anesthesia and also performs the procedure, use 93312-59. However, the report should state what diagnostic processes were occurring that required the TEE (such as valvular function after surgical placement of a new valve).

If the anesthesiologist is trained to do more than place the TEE probe, Ryan says, some insurance companies must have the physician's certification on file so that he or she can receive appropriate reimbursement. Ask if your carriers require this.