Cardiology Coding Alert

Knowing how to code congenital TTE and TEE can make all the difference

You can code echocardiography backward and forward - but will you be ready when your cardiologist sees a patient for congenital heart disease? If an echocardiogram reveals any congenital anomaly, even one that will resolve itself, you should focus on the separate congenital echo codes.

Cardiologists don't have to specialize in pediatrics to treat congenital heart disease (CHD). Although most CHD patients are children (typically newborns or infants under 2 years), adults may also have congenital heart anomalies that require treatment.

Often that treatment involves complex technical skills and high-risk surgery to correct problems, meaning the cardiologist must spend more time evaluating the congenital anomalies. Distorted anatomy makes the usual series of steps - for catheterization, as an example - much more difficult, thus making coding unique.

The rule is: If the results of an echocardiogram confirm a congenital anomaly, you should use the congenital codes, says Cynthia Swanson, RN, CPC, a cardiology coding specialist with Seim, Johnson, Sestak, and Quist LLP in Omaha, Neb.

TTE Sometimes Prevents Need for Preoperative Cath

Two codes specifically describe transthoracic echocardiography (TTE) for congenital anomalies: 93303 (Transthoracic echocardiography for congenital cardiac anomalies; complete) and 93304 (Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study).

Cardiologist use TTE on children and young adults to obtain accurate anatomic definition of most congenital heart diseases. TTE can sometimes prevent the need for preoperative catheterization.

You should report CPT 93303 when the physician performs a complete echocardiogram on a patient to assess septal defects (ICD-9 745.4, Ventricular septal defect; and 745.5, Ostium secundum type atrial septal defect) or other cardiac congenital anomalies, says Sheldrian LeFlore, CPC, senior consultant with Gates, Moore & Company in Atlanta.

Heads up: Your cardiologist may suspect a congenital anomaly and order an echo, but the congenital anomaly must be present to use 93303 and 93304.

Otherwise, you would revert back to the noncongenital echo codes 93307 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; complete) and 93308 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; follow-up or limited study).

For example: A 23-year-old woman complaining of shoulder pain undergoes a chest x-ray. The x-ray demonstrates prominent pulmonary vessels, and her cardiologist orders a TTE. The TTE reveals a secundum atrial septal defect (745.5, Ostium secundum type atrial septal defect) with obvious left-to-right shunting on color Doppler.

You should use 93303 for a complete TTE for the congenital anomaly, in addition to the Doppler (+93320, Doppler echocardiography, pulsed wave and/or continuous wave with spectral display [list separately in addition to codes for echocardiographic imaging]; complete) and color flow (+93325, Doppler echocardiography color flow velocity mapping [list separately in addition to codes for echocardiography]) codes.

Carriers Need TTE Details
 
Most carriers recognize the increased complexity of congenital disease procedures and will reimburse at a higher relative value unit (RVU) than normal echocardiography codes. You must show documentation supporting medical necessity.

For instance, if your cardiologist characterizes the patient's conditions as stable, continual or serial and wants to use the TTE for assessment that exceeds an annual evaluation, you must back these codes up. 

South Carolina Palmetto GBA advises coders, "TTE performed more frequently than annually will require documentation to support medical necessity." 

However, other less stringent carriers allow multiple echos to be performed in a year prior to necessitating additional documentation. 

If TEE High-Res Images Show Congenital Anomaly, Use Congenital TEE Codes

When the TTE does not yield sufficient results, your cardiologist may lean on transesophageal echocardiography (TEE) for answers.

Like the TTE, specific congenital codes exist for the TEE as well, and you can use these codes if the images reveal any congenital anomaly, no matter how little the clinical value.

"A TEE may be effectively utilized in early postoperative cases where the diagnostic quality of a TTE is impaired, " says WPS, a Part B provider in Wisconsin. In other words, TEE can display abnormalities that TTE may miss, because the cardiologist places the probe closer to the cardiac structures and displays high-resolution images.

When your cardiologist performs a TEE to assess congenital anomalies, you should report 93315 (Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report), 93316 (Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only) and 93317 (Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only).

Most carriers have lists of specific diagnosis codes that support medical necessity, so start by ensuring that the diagnosis can be found on that list.

Some commonly accepted diagnoses include 444.81 (Embolism and thrombosis of iliac artery), 458.9 (Hypotension, unspecified), 745.4 (Ventricular septal defect) and V42.1 (Heart replaced by transplant).