Stress Tests and Transthoracic Echocardiograms

A stress test evaluates a patient’s heart during physical or pharmacological stress and is generally performed on a bicycle or treadmill. During a stress test a patient will usually exercise until symptoms occur or patient reaches a maximum heart rate (85% of predicted heart rate based on age). If the patient is physically unable to exercise or is taking medications that depress heart rate, pharmacological stress can be substituted for exercise. Pharmacologic stress agents can be billed separately by the entity that provides them. Common stress agents are Adenosine, Dobutamine, Dipyridamole and Arbutamine.

To report both exercise and pharmacologic stress: 

• 93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report 
• 93016 – physician supervision only, without interpretation and report 
• 93017 – tracing only, without interpretation and report 
• 93018 – interpretation and report only

Under CCI edits, codes for electrocardiogram (93000-93010), rhythm strip (93040-93042), pulse oximetry (94760-64761) and Injection or Infusion (90774) are all included in the stress test and should not be reported separately.

Echocardiograms

Echocardiography uses high frequency sound waves to record the structure of the heart and blood flow within the heart. Transthoracic echocardiograms (TTE) are the most common type of echo performed. During TTE a transducer is moved on the surface of a patient’s chest to obtain images that are captured for analysis. EKG monitoring is also performed to assist in evaluating the heart in different stages of cardiac cycle. Heart chamber size, contraction, wall motion, wall thickness and valve structure can all be evaluated using echocardiography. Doppler echocardiography is often used to detect acute complications following a myocardial infarction. 

Doppler color flow imaging evaluates the blood flow through the heart and displays flow data on 2-D echocardiographic image. Doppler wave form imaging provides directional information about flow, velocity and characteristics. Wave form is obtained when a transducer transmits a series of pulses to detect motion. 

To report TTE: 

93303–Transthoracic Echocardiography for congenital anomalies; complete 

93304 – follow-up or limited study 

*Please note codes 93303-93304 are to be used for patients with congenital anomalies only 

93306-Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler and color flow Doppler echocardiography (93320 and 93325 are now bundled with this code and should not be reported separately)

93307–Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral Doppler or color flow Doppler echocardiography 

93308-follow-up or limited study

 + 93320 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display.

 + 93321 - follow-up or limited study

 + 93325 - Doppler echocardiography color flow velocity mapping

Sometimes a physician will order a Stress Echocardiogram to evaluate the motion of the heart's walls and pumping action when the heart is stressed. This will help him/her to better determine a lack of blood flow that isn't always apparent on other heart tests. During a stress echo images are recorded before, after and sometimes during stress. Patient’s EKG, heart rate and blood pressure are also monitored before, during and after test. The goal is to evaluate hemodynamic, electrocardiographic and echocardiographic responses to stress.

To report stress echo: 

93350 - Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle and/or pharmacologically induced stress with interpretation and report

 + 93352 Use of contrast agent during stress echocardiography