Internal Medicine Coding Alert

The codes for transthoracic echocardiography (TTE, 93303-93308) are among the 50 most frequently reported procedure codes in internal medicine, according to utilization statistics from HCFA. Many internists, however, are losing revenue by failing to bill separately for a Doppler echocardiography that is often performed with a TTE. Internal medicine coders should use add-on codes for Doppler echocardiography and the correct diagnosis code to ensure proper payment for these procedures.

Understanding and Identifying TTE Codes

TTE is a noninvasive test that uses ultrasonic signals and two-dimensional imaging to examine the size, shape and motion of the heart and great vessels. The primary code used to report TTE is 93307 (echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete), according to Jim Stephenson, president of North Central Medical Management, a multispecialty medical billing company in Elyria, Ohio. Another commonly used echocardiography code is 93350 (echocardiography, transthoracic, real-time with image documentation [2D], with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report). Code 93350 is reported when a TTE is performed with a stress test.

The last code used to report TTE is 93303 (transthoracic echocardiography for congenital cardiac anomalies; complete) and should only be used to report cardiac conditions that have been with the patient from birth.

Reporting Echocardiography and Color Dopplers

An internist will often order a Doppler echocardiography with the TTE. The Doppler echocardiography uses ultrasound to determine the direction and velocity of blood flow within the cardiovascular system. Code 93320 (Doppler echocardiography, pulsed wave and/or continuous wave with spectral display) should be reported in addition to 93307 when a Doppler echocardiography is performed with a TTE.

Another procedure often performed with a TTE is Doppler color flow velocity mapping (93325, Doppler echocardiography color flow velocity mapping [list separately in addition to codes for echocardiography]). The color Doppler is a qualitative assessment of the blood flow, and the use of color makes it easier to identify abnormal flow patterns, according to Michael Haynes, MD, FACP, an internist and pulmonologist who is also the compliance director at University Medical Associates in Augusta, Ga.

Both 93320 and 93325 are add-on codes, which are reported in addition to the main TTE procedure, says Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group in Stuart, Fla. Add-on codes do not require the use of modifier 51 (multiple procedures) or -59 (distinct procedural service). But the Doppler add-on codes must always be reported with a TTE code, she says. These codes cannot be reported independently. It is not unusual for both Doppler procedures to be performed during the same session. In almost all of our diagnostic studies, all three procedures are used, Haynes says.

Use Modifier -26 With Add-on Codes

One modifier that may be used with the TTE and Doppler echocardiography codes is modifier -26 (professional component). All of these echocardiography codes include both a technical and a professional component. The technical component represents the value assigned to the ownership and maintenance of the equipment and the use of any technicians. For an internist to bill for the technical component of any diagnostic service, he or she must own (or partially own by being a partner in a practice) the equipment being used. If the echocardiography is done in a hospital setting, the hospital bills for the technical component of the test.

The professional component represents the internists interpretation of the test results. When the internist performs only the interpretation of the echocardiography, perhaps by reading the recorded results on the strip chart, he or she may bill for reimbursement of the professional component by attaching modifier -26 to the procedure codes.

If the echocardiography is performed in a hospital setting, the internist should bill only for the professional component, says Stephenson, who adds that the TTE, Doppler echocardiography and color Doppler codes all have professional components. Therefore if an internist reports only the professional component of 93307, he or she will probably report only the professional component of any Doppler echocardiographies that may be performed as well.

The internist, however, must interpret the test to report the professional services component. Some internists who order a TTE for their patients and send them to the hospital for the test will not bill anything because someone at the hospital and not the internist interpreted the test, cautions Pride.

Add-on Codes May Require Different Diagnosis

It is important to report a covered diagnosis code for the add-on codes as well as the main TTE procedure code. Just because a diagnosis is covered for the TTE, however, does not mean that it is a covered diagnosis for the add-on code. Internists often order a TTE with a diagnosis of hypertension, but it may not be covered by some payers for the Doppler echocardiography, Pride explains. In this situation, the diagnosis code for the Doppler could be different from the one used for the TTE.

The internist may have to justify through the use of the diagnosis code why he or she ordered the additional Doppler echocardiography because many payers, including Medicare, do not cover the Doppler procedures when performed routinely with the TTE. If an unsuspected finding on TTE indicates medical necessity for an additional study with Doppler color flow velocity mapping, it can be covered, reads the local medical review policy (LMRP) of Nationwide Medicare Services, the local carrier for Ohio and West Virginia. If there is no specific finding, however, the test is considered a routine screening examination, which is not covered by most payers and should be billed to the patient.

If the internist does not write down a covered diagnosis code on the fee slip, the coding staff should check the patients medical record to see if the internist noted any other signs, symptoms or conditions that would be covered, suggests Stephenson. Frequently, the patient will complain of chest pains (786.50), shortness of breath (786.05) or wheezing (786.07), which are commonly covered diagnoses for this procedure.

How to Report Followup Dopplers

For followup or limited TTEs, coders should use 93308 (echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; followup or limited study) to report a follow-up echocardiography. Code 93321 (Doppler echocardiography, pulsed wave and/or continuous wave with spectral display [list separately in addition to codes for electrocardiographic imaging]; followup or limited study) is another add-on code used to report a followup Doppler echocardiography and can be reported with either the complete or followup TTE. There is no followup code for a Doppler color flow velocity mapping.

A diagnosis code also has to be reported with followup codes, and its selection may be more complex than for the complete examination. Followups are not that common; one may be done six months after heart surgery, says Stephenson. They are only used for certain diagnoses. Many carriers, for example, will cover the followup TTE for a diagnosis of benign (402.10) or malignant (402.00) hypertensive heart disease without congestive heart failure. However, that diagnosis is generally not covered for 93321, so the internist will have to use a different diagnosis to report the Doppler followup.

Because covered diagnosis codes for these procedures can vary by payer, internists should contact their local payers for a complete list of covered and noncovered diagnosis codes. While this requires extra work on the part of the internist, the correct use of these add-on codes can boost reimbursement for echocardiographies. These are some of the better paying codes, Stephenson says.

Note: TTE should not be confused with transesophageal echocardiography (TEE, 93312-93318). The Doppler echocardiography codes can also be used with TEE, but in this procedure the transducer is passed through the mouth into the esophagus and the two-dimensional images are obtained from the posterior aspect of the heart. Most Medicare carriers have a separate LMRP for TEE procedures.