Cardiology Coding Alert

Proceed with caution when you're tempted to report 93314 twice.

CMS's Medically Unlikely Edits suggest that reporting two transesophageal echocardiograms (TEEs) on the same date for a single patient is OK. But proving necessity for that second TEE is easier said than done.

In last month's issue, "Tackle Proper TEE Coding for Cleaner Claims" covered when to use the codes specific to congenital anomaly cases, as well as the roles of modifiers 26 (Professional component) and TC (Technical component).

 Now take a look at what to do when documentation points to multiple TEEs on a single date.

Prepare to Support Billing Multiple TEEs

You may bill a TEE more than once per day when new indications or symptoms warrant the additional TEE at a separate session, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder with St. Joseph Heart & Vascular Center in Tacoma, Wash.

For example: J1 Part B MAC Palmetto's local coverage determination (LCD) L28254, states: "Repeat echocardiographic studies should be guided by the clinical status of the patient ... Repeat studies are appropriate to monitor changes in cardiac structure or function when there are clinical changes in the status of the patient, or when disease progression is otherwise suspected."

Caution: Often, circumstances will support reporting only one TEE service. For example, when the physician performs a TEE for screening purposes, the TEE is limited to one per day, Neighbors says. You also should not code an additional TEE if it is a follow-up TEE to a diagnostic procedure (for example, a PFO/ASD closure) if there are no new indications or symptoms to warrant an additional TEE, she says. So, "when a follow-up TEE is provided to verify if a diagnostic procedure is successful, it is inclusive within the primary diagnostic procedure," she explains.

On the other hand: When new indications or symptoms warrant an additional TEE at a different session on the same date, you may consider reporting an additional TEE code, says Neighbors.

Inspect Intraoperative Rules More Closely

"During a surgical procedure the physician will rarely have enough medical necessity to code multiple TEEs during the same session on a patient," Neighbors warns. The second TEE is usually provided for verification that something worked or was successful, not because a medical indication or symptom made the second TEE necessary, she explains.

In fact, Highmark, the J12 Part B MAC, specifies in its LCD (L27535) that "To be a covered service TEE must include a complete interpretation/report by the performing physician. Only one interpretation will be covered per operative session," points out Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, of Perfect Office Solutions in Leesburg, Fla. Individual payer policies may vary, points out Dennis.

Remember: "The intraoperative TEE is not the same as a TEE for monitoring purposes. If a TEE for monitoring purposes is being performed during the surgery the appropriate procedural code would be CPT 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]," Neighbors says.

Clue In to Proper Code Use

Don't forget to choose your TEE code based on the services the cardiologist performs.

For example: Often, for a cardiac bypass, the anesthesiologist, not the surgeon, delivers the TEE probe. That means you should not report the complete TEE (93312, Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]; including probe placement, image acquisition, interpretation and report) for the surgeon, Neighbors points out. Instead, 93314 (... image acquisition, interpretation and report only) would be appropriate.

Note that for payers who apply Correct Coding Initiative (CCI) edits, you will not be able to report 93312 and 93314 together on the same claim. The edit for these codes has a modifier indicator of 0, so you may not override the edit. This edit adds support to the argument that you may not report a complete TEE and then report a follow-up TEE using 93314 while the probe is still in place.

But Medicare's Medically Unlikely Edits (MUEs) add support to the possibility of reporting multiple TEEs on the same date. Codes 93312, 93313, and 93314 each have an MUE of 2, meaning that's the maximum number of times the average patient will have a TEE on a single day.

Lesson learned: "The need for a repeat TEE study is based upon the findings of the original study and/or the new indications/symptoms," Neighbors says. "The documentation explaining the reasons why and how a repeat study will affect the patient care/management is required to support medical necessity." And note that "when a repeat or follow-up study is performed, usually a limited study is provided," she says. So make sure you assign the appropriate codes.