Peering into the Heart: A Fresh Look at Anesthesia TEE Services

 Summary

The rules for billing and documenting TEE services can seem complex and confusing. What type of TEE is billable? What credentials are necessary to perform a TEE? What documentation do I have to provide to ensure I get paid? These and other questions are addressed and answered in today's article.

Not everyone can look into the human heart and understand its complexities. Who among us can really know what goes on inside another person, or even ourselves? While most us will never be able to plumb the depths of the emotion and intention that reside within the metaphysical heart, there are those who have the capacity to peer into the dark and evaluate its physical counterpart; and they do this through the use of transesophageal echocardiography, or "TEE."

Ultrasound imaging of block placements, invasive lines and even heart function have increasingly fallen under the purview of the anesthesia department. Providers hailed for their skill in eliminating pain are often equally adept at utilizing advanced imaging technology and providing diagnostic interpretations of these cardiac images. It is appropriate, therefore, that these additional skills and services are separately compensated. Today's article addresses the nuances of certification, coding, payment and documentation connected with TEE services.

Credentialed in TEE

Just as you must have certain credentials to perform anesthesia services, those performing TEE services must also meet certain requirements in order to bill for these services. The problem is that these requirements differ based on payer, state and/or facility. For example, CGS Administrators—the Medicare administrative contractor for certain states in the Midwest—published a Local Coverage Determination (LCD) that provides for multiple options in demonstrating TEE expertise sufficient to authorize payment. Here is the relevant excerpt from that LCD:

For the professional portion, an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting any one of the following requirements:

• The physician is board certified in Cardiovascular Diseases or Perioperative Transesophageal Echocardiography (National Board of Echocardiography); or
• The physician has Level II training in transesophageal echocardiography (including documentation of the performance of 25 esophageal intubations and 50 supervised interpretations), as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, or the equivalent of Level II training as set forth in that document, or
• The physician has been credentialed for this procedure by the hospital where the physician performs this service.

Did you notice that little word "or" at the end of each bullet? Based on this verbiage, CGS gives you an option as to how you might go about obtaining authorization to bill for TEE services. You can go through the long and arduous process of earning some level of certification OR you can simply have hospital privileges to perform TEE. If the hospital gives the okay, you're good to go! Again, this is only one payer's approach. Others will have similar requirements, more stringent requirements, or no published requirements at all.

The American Society of Anesthesiologists (ASA) has also written on this topic, stating that "Only physicians with appropriate training or comparable experience in perioperative TEE, and who have been credentialed for basic or advanced perioperative TEE, should perform perioperative TEE." Given this fairly broad recommendation, as well as the varying degrees of requirements we may find per payer or per state, it will be up to each TEE provider to ensure he/she has met the credentialing requirements in his/her location sufficient to bill for the TEE service. If you document TEE services, it will be up to you to inform us if you have not met these requirements.

Types of TEE

It is important to understand that there are different CPT codes that reflect the array of TEE services an anesthesiologist might perform. Here are the primary codes at issue, along with a brief description of each:

• CPT 93312 – Probe placement and interpretation. This code is used when an anesthesiologist places the TEE probe AND performs a diagnostic interpretation, which is memorialized in a formal report.
• CPT 93313 – Probe placement only. You would bill this code when you only placed the probe, but did not personally perform the interpretation.
• CPT 93314 – Interpretation only. If you did not place the probe, but performed the interpretation and submitted a formal interpretive report, this is the code you would bill.
• CPT 93318 – Intraoperative monitoring. This code reflects a TEE service that was only for the purpose of intraoperative monitoring—rather than a diagnostic purpose—with no interpretive study or formal report being performed.

Again, these are the primary TEE services typically performed by anesthesiologists. Most of these codes are always payable. One of them, however, is only occasionally payable, as further described in the following section.

Distinction in TEE

The Centers for Medicare and Medicaid Services (CMS) has advised that it will only pay for "diagnostic" TEE services. It has further determined that the services described by CPT 93318 do not meet that definitional threshold. Medicare considers such services, as described by this code, to be bundled into the anesthesia service. Therefore, intraoperative monitoring TEE services will not be paid by Medicare or any other payer that follows Medicare's National Correct Coding Initiative (NCCI) bundling rules.

All this raises the question: what constitutes a diagnostic TEE? Ultimately, this will be up to the clinical judgment of the physician performing the service. It is clear that at the very least there must be an interpretive study and formal report that supports the diagnostic designation. For example, the American Medical Association (AMA)—the entity that creates and defines the CPT codes—has stated that a TEE service could not be considered diagnostic unless someone (you, your partner, the cardiologist) performed an interpretive study and provided a formal report. So, in order for you to bill 93313, someone has to bill 93314, the interpretation-only code. If you performed both the placement and the interpretive diagnostic study/report, you would of course be able to bill for 93312.

Document the TEE

From a billing and coding perspective, it is important that we receive from our clients the appropriate documentation reflecting their TEE services. Here is what we request as to both anesthesia record notations and other medical documentation:

1. Where a TEE is indicated on the anesthesia record, you must document the full range of the service (e.g., "probe placement only," "probe placement and interpretation," "interpretation only").
2. You must indicate the purpose of the TEE: "Diagnostic or "monitoring." If the word "diagnostic" is not on the record, and we have no other medical record to indicate you performed a diagnostic service, the service will reflect monitoring (typically not billable).
3. If your TEE service was diagnostic, reflecting either code 93312 (placement and interpretation) or 93314 (interpretation only), then you should submit the TEE report to us at the time you submit the associated anesthesia record. If the diagnostic TEE service was probe placement only (93313), you are not responsible for sending us the report as it was produced by a different provider. However, you should be sure that such a report by the cardiologist or your partner was, in fact, generated before labeling the service as "diagnostic."

Final Thoughts

The rules covering the designation, documentation, submission and payment of TEE services can be complex as different entities have provided varying points of view over the years. As your billing partner, we continue to review the best available and authoritative materials to ensure that the submission of your claims will be both accurate and compliant.

There are other services that are sometimes billed in addition to TEE that were not covered in this alert. These "TEE modalities" (e.g., pulse wave, color flow, 3D imaging) will be addressed in a future article. As always, it is our pleasure to provide insight and guidance in the area of anesthesia and ancillary services. Our years of experience in this industry has allowed us to glean information we hope you will continue to find helpful. If you have further questions regarding TEE services, including those that may not have been discussed in this article, please reach out to your account executive or contact us at info@anesthesiallc.com