Anesthesia Coding Alert

Not all code options apply to every provider.

Transesophageal echocardiography (TEE) is a specialized service that anesthesiologists sometimes provide during cardiovascular cases. Your provider will need certain training credentials before performing and billing for TEE, and payers expect certain documentation before reimbursing for the service. Our experts offer real-world tips to help you find TEE coding success.

Ensure Your Code Knowledge Is Up-to-date

CPT^® 2017 includes seven codes related to TEE. They don't all apply to anesthesiologists, but it's still important for you to know what they each cover:

• 93312 – Echocardiography, transesophageal, real-time with image documen­tation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
• 93313 – ... placement of transesophageal probe only
• 93314 – ... image acquisition, interpretation and report only
• 93315 – Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
• 93316 – ... placement of transesophageal probe only
• 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.

One more related service: Another TEE code in CPT® is 93355 (Echocardiography, transesophageal [TEE] for guidance of a transcatheter intracardiac or great vessel[s] structural intervention[s] [e.g., TAVR, transcatheter pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure] [peri-and intraprocedural], real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D). Don't add this one to your coding arsenal, however, because it describes a service different than what your anesthesiologist will provide. In addition, code 93355 cannot be used in conjunction with codes 93313-93318.

Another important point: According to the American Society of Anesthesiologists, CCI edits pair anesthesia services with TEE as described by code 93355, says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Pay Attention to Coding Guidelines

Each TEE code from 93312-93318 includes notes explaining how you should – or should not – report them on your claim. For example, you cannot report codes 93313-93318 with 93355. You also have some guidelines specific to certain codes and tips that CPT^® and coding experts offer to help you correctly report the service. These include:

• Code 93312 may be appropriate for those anesthesiologists who have credentials to perform the entire TEE procedure, interpretation and report.
• Code 93313, by contrast, does not include the TEE interpretation and report. Submit 93313 when your anesthesiologist places the probe but a cardiologist performs the interpretation and report.
• Code 93314 coincides with 93313. If your anesthesiologist reports 93313, the cardiologist must report 93314.
• You may be able to report 93315 if your anesthesiologist is credentialed to perform the entire TEE procedure, especially if he specializes in cardiac anesthesia. You should bill 93316-93317 only if the anesthesi­ologist didn't provide all services described by 93315.
• 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.
• Your anesthesiologist might report 93318 most often, due to using TEE probes for monitoring.

Red flag: Some payers do not reimburse 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.

"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 furnished 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.

Watch for Notes About Moderate Sedation

The 2017 code set revises this code by removing moderate sedation, also called conscious sedation, from this procedure. Use of moderate (conscious) sedation is no longer considered an inherent part of this procedure and you can now report it separately.

Prior to the 2017 change, reimbursement for moderate (conscious) sedation was built into the compensation for the procedure as the anesthesia was administered by the same physician or other qualified health care professional who performed the procedure. This code included conscious sedation as an inherent part of providing the service and was not separately reportable. It has been recognized that practice patterns for some procedures have changed, with anesthesia increasingly reported separately by a provider separate from the one who performs the procedure. For this reason, CPT^® 2017 unbundles moderate (conscious) sedation from hundreds of codes.

You also have new codes for moderate sedation, beginning this year. To report moderate (conscious) sedation when provided by the same physician or other qualified health care professional who performs the procedure, choose from:

• 99151 – Moderate sedation services provided by the same physician or other qualified health care profes­sional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
• 99152 – ... initial 15 minutes of intraservice time, patient age 5 years or older
• 99153 – ... each additional 15 minutes intraservice time (List separately in addition to code for primary service).

If you're reporting moderate sedation services provided by a physician or other qualified health care professional other than the provider performing the procedure, you'll choose from a different set of codes:

• 99155 – Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
• 99156 – ... initial 15 minutes of intraservice time, patient age 5 years or older
• 99157 – ... each additional 15 minutes intraservice time (List separately in addition to code for primary service).

Bottom line: As with any care your anesthesiologist offers, only report the portion of the service he or she provides. Verify training and certifications to know which TEE codes are possibilities, and let the documentation guide you from there.

"Coders also need to remember that they should not report a lower service, such as billing for placement of the TEE probe (with 93313) when the anesthesiologist placed the probe for monitoring (code 93318) just to get the service paid," Dennis warns.