A Further Take on TEE: Going Beyond the Basics

Summary

Anesthesia providers have long been familiar with the basic TEE services and the primary TEE codes, but are they are aware of additional services that relate to TEE that are also available? Which of these are actually billable and what are the clinical and documentation standards for each? These are some of the questions we hope to answer in today's article.

A couple of weeks ago, we took a look at transesophageal echocardiography (TEE), focusing on the primary TEE services that an anesthesiologist might document on the anesthesia record: probe placement, interpretation, placement and interpretation and intraoperative monitoring. This week, we want to follow up with a discussion of other services involving TEE that the anesthesia provider may also perform. This will include a look at additional services that are sometimes billed in conjunction with the foundational TEE services mentioned above. These additional services are often described as "TEE modalities." In addition, we will look at a rarely used TEE code that has generated some curiosity among some of our clients. Finally, we will address anesthesia for TEE procedures.

It may be beneficial to include language directly gleaned from the American Society of Anesthesiologists (ASA) "Statement on Transesophageal Echocardiography," developed by the ASA's Committee on Economics, as revised in 2015. To that end, much of the material below contains excerpts from that statement.

TEE Modalities

In this section, we will provide a CPT descriptor and utilization commentary relative to each TEE modality code. We will then offer some documentation guidelines for billing purposes.

+93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete

ASA Comment: This add-on code is used to evaluate blood velocity and flow patterns through various cardiac and vascular structures. Stenotic lesions generally lead to increased blood velocity proportional to the degree of stenosis, thereby providing a method to assess the severity of stenosis. Velocity measurements are also used to calculate the area of stenotic valves and regurgitant orifices.

Documentation Guide: As this is an add-on code, you first need to make sure you have documented the foundational service (e.g., TEE placement, interpretation). Then, you will need to denote (on a medical record we receive) the "magic words," i.e., words that match the actual terms used in the code descriptor for 93320. This will give our coders a clear indication of the service you performed. For example, you might document: "doppler using pulsed wave."

+93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)

ASA Comment: This add-on code is used to evaluate the direction and character of blood flow through various cardiac and vascular structures.

Documentation Guide: The same basic guidelines given for 93320 also apply here, except the "magic words" for 93325 should include verbiage that accentuates the term "color flow" within your overall documentation of this service.

76376 - 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation

ASA Comment: Physicians requesting 3D services should generate a written request indicating the clinical need for the additional 3-D imaging and that the interpreting physician's report address those specific clinical issues. CPT code 76376 may be considered medically unnecessary and denied if equivalent information obtained from the test has already been provided by two-dimensional ultrasound.

Documentation Guide: For our billing purposes, you're going to want to document at least the following terms: "3D imaging" (or its equivalent) and "not independent workstation." Because this code contains language about "interpretation and reporting," the anesthesiologist hoping to bill for this service must complete and retain in the patient's chart an interpretive report, to include indications of supervision. Ideally, this report—which may be included in the overall TEE report—should be sent to our billing office.

76377 - 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation

ASA Comment: Physicians requesting 3D services should generate a written request indicating the clinical need for the additional 3-D imaging and that the interpreting physician's report address those specific clinical issues. CPT code 76377 may be considered medically unnecessary and denied if equivalent information obtained from the test has already been provided by two-dimensional ultrasound.

Documentation Guide: The rules covering documentation of 76376 will also apply to this code, except that you will need to specify that the service involved an "independent workstation."

That "Other" TEE Code

In 2015, the AMA created a new code that initially generated a great deal of interest among anesthesia providers. However, it wasn't long before cold water was thrown on the fire as most billing experts determined that this code would never be billable by an anesthesia provider. Nevertheless, we have clients who, from time to time, still inquire about the use of this code within their practice. So, what's the story on this "other" TEE code? Let's begin by looking at its descriptor.

93355 - Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg, TAVR, transcatheter pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra- procedural), 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

Now, that's a mouthful! Rather than dissect this unusually verbose descriptor ourselves, let's look at how the ASA treated this code in its 2015 statement:

This service involves placement of the transesophageal probe, obtaining the appropriate images and views, and critical analysis of the images and data for patients undergoing major transcatheter cardiac or vascular intervention. Patients undergoing these procedures have cardiovascular disease and may have co-morbidities of such severity that they are deemed too high risk for an open procedure. These patients are at increased risk for hemodynamic disturbances due to cardiovascular lesions, which include, but are not limited to, severe valvular heart disease, intra- cardiac defects, and aortic aneurysm. Diagnostic interpretation of the TEE data guides selection and positioning of implanted devices, determines successful deployment, and identifies complications. It is not appropriate to separately report spectral Doppler, color flow Doppler, 3D echocardiography, or administration of ultrasound contrast.

In addition to this primarily clinical description, we must add a few of our own observations. The most important thing we can say here is that 93355 is ALWAYS bundled into both the anesthesiologist's service, as well as the surgeon's service, according to Medicare's National Correct Coding Initiative (NCCI). In order for it to be billed, a third party—who is not billing for the surgery or the anesthesia—would have to perform the service and submit the claim.

Anesthesia for TEE

Just as there are occasions when a provider might bill an anesthesia code where the primary procedure is a chronic pain block, occasionally we see one of our clients submitting an anesthesia record where the primary procedure is a TEE probe placement. The commonality between both these scenarios is that it's typically anesthesiologists who actually perform both pain blocks and TEE services. In these cases, however, the anesthesiologist is not performing either, but rather provides the anesthesia as to each service.

When performing anesthesia for TEE, the ASA's Crosswalk manual recommends billing anesthesia code 01922 (7 base units), anesthesia for non-invasive imaging or radiation therapy, in relation to the following TEE codes:

• Probe placement AND interpretation, 93312; and
• Probe placement only, 93313

The ASA Crosswalk lists the following comment for the interpretation-only code, 93314: "ANESTHESIA CARE NOT TYPICALLY REQUIRED"; and, significantly, it does not even list code 93318, the code for intraoperative monitoring. This is a clear indication that the ASA does not consider this code as warranting an anesthesia service—ever.

We know that some payers have increasingly balked at paying for an anesthesia service to cover a pain block. Similarly, there may be difficulty in securing payment for an anesthesia service that covers only a TEE procedure. You will want to be sure that you meet the requirements for the payer in question for such cases. For example, some health plans may require certain co-morbidities, age parameters or patient histories before payment can be effectuated (think Medicare MAC policy).

Conclusion

Years ago, there was a commercial for a kid's toy with the catchy jingle: "Transformers—more than meets the eye." In a sense, the same can be said for "transesophageal echocardiography," except that doesn't roll off the tongue quite as well! However, there is more to TEE than just the basic placement and interpretation codes, as today's article has clearly demonstrated. So, what we want our clients to do is to ask themselves the following questions: Am I performing these ancillary TEE services? If so, am I sufficiently documenting them so that I can get paid? Should I be performing any of these additional TEE services? If so, which ones?

We at ABC are here to help you navigate the multifold billing and coding issues surrounding TEE and other services.