Draft Article - Billing and Coding: Transesophageal Echocardiography (TEE) (DA52868)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Transesophageal Echocardiography (TEE).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.CPT codingIntraoperative TEE is reimbursable to a cardiologist or other physician who is not part of the surgical/anesthesia team but only when performed as a diagnostic test and not for monitoring purposes (TEE for intraoperative monitoring is included in the anesthesia care). However, when performed by cardiologist or other physician who is part of the surgical/anesthesia team for diagnostic purposes with documentation including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service.Use procedure code 93312 (C8925 for OPPS billing when contrast is used) or 93315 (C8926 for OPPS billing when contrast is used) for the complete procedure, including probe placement, image acquisition, interpretation and report. Code 93315 (C8926 for OPPS billing when contrast is used) should be used for congenital anomalies only.Use procedure code 93313 or 93316 where the provider is reporting only the insertion of the transesophageal probe. Code 93316 is reserved for congenital anomalies only.Use procedure code 93314 or 93317 where the provider is reporting the actual manipulation of the probe to obtain images and to provide an interpretation and report. Code 93317 is reserved for congenital anomalies only.CPT code 93318 (C8927 for OPPS billing when contrast is used) (intraoperative monitoring) is considered part of an anesthesia service and should not be billed separately by the anesthesiologist.CPT codes 76376 and 76377 and 93319 (3D echocardiography) should be billed in conjunction with the base code for the imaging procedure. For the purposes of this LCD, the base codes for CPT 76376 and 76377 are 93312, 93314, C8925, 93315, C8926, and 93317 and the base codes for CPT 93319 are 93312, 93314, 93315, C8926, and 93317.Diagnosis codingICD-10-CM code R93.1 or R93.8 should be reported when a TEE (CPT codes 93312, 93313, and 93314) is performed because of inadequate visualization of cardiac anatomy on TTE, for structures normally visualized by TTE and for which TEE is not usually indicated. ICD-10-CM code R93.1 or R93.8 should be reported as the primary diagnosis and the cardiac abnormality should be coded as a secondary diagnosis.ICD-10-CM code Z01.89 should be reported when a TEE is performed during an open chest procedure. ICD-10-CM code Z01.89 should be reported as the primary diagnosis and the reason for the surgical procedure should be coded as the secondary diagnosis.For add-on CPT codes 93319, 93320, 93321 and 93325, the ICD-10-CM codes reported should be the same as those reported for the base codes to which they are attached.Bundled servicesProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.CPT codes 93312-93318 include conscious sedation. Therefore sedation should not be billed separately, and if it is, will be bundled into the primary procedure code.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.For claims submitted to the Part A MAC:The OPPS does not apply to claims for every type of bill submitted by Medicare-certified providers. The following guidelines pertain to claims for bill types that are subject to the OPPS:Hospitals are required to include HCPCS codes for all services paid under the OPPS.HCPCS codes C8925, C8926, and C8927 should be used to report transesophageal echocardiography services by OPPS hospitals when contrast is used. If the transesophageal echocardiography services are performedwithoutcontrast, OPPS hospitals should report CPT codes from the 9xxxx series, as appropriate.Every effort should be made to report all services performed on the same day on the same claim to assure proper payment under the OPPS. Claims submitted for the same date of service will be returned to the provider (except duplicates or those containing condition code 20 or 21) with a notification that an adjustment bill should be submitted (CMS Program Memorandum, Transmittal No. A-00-36, Change Request #1229, June 2000).Documentation Requirements:A covered service must include a complete interpretation/report by the performing physician, and must be available if requested.The patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, as well as reasons for repeat testing.In those instances in which repeat tests were denied, the physician must document a good faith effort was made to identify them and to request copies of them from previous providers, in order for NGS to consider reimbursement for such tests on appeal.Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. All appropriate measurements should be included in the report.A Doppler interrogation should state the modes used and should give both qualitative and quantitative information.Documentation of the qualifications of personnel performing tests, as described in the Indications section of the LCD, should be available on request.All documentation must be submitted upon request.Utilization Guidelines:TEE services will be covered twice per year for all conditions except endocarditis (ICD-10 code I39), for which four (4) services per year will be covered.TEE may be repeated in patients with repeat episodes of atrial fibrillation/flutter prior to cardioversion.Services exceeding this parameter will be considered not medically necessary, unless there is documentation that the tests were performed for clinical indications reflecting a change in the patients status or underlying cardiac condition, or documentation of a new unrelated condition, sign or symptom.In those instances in which repeat tests were denied and a physician has documented a good faith effort to identify them and to request copies of them from previous providers, then NGS could reimburse such tests on appeal.These guidelines do not apply to tests performed on hospital inpatients.