Transesophageal Echocardiography (TEE) CODING NOTES

  2011 Transesophageal Echo CPT® Codes:

  93312 TEE with 2-D, M-mode, probe placement, image acquisition, interpretation and report

  93313 TEE probe placement only

  93314 TEE image acquisition, interpretation, and report only

  93315 TEE for congenital anomalies with 2-D, M-mode, probe  placement, image acquisition, interpretation and report

  93316 TEE for congenital anomalies, probe placement only

  93317 TEE for congenital anomalies, image acquisition, interpretation and report only

  93318 TEE for monitoring purposes, ongoing assessment of cardiac pumping function on an immediate time basis



  2011 Doppler Echocardiography CPT® Codes:

  93320 Doppler echo, pulsed wave and/or spectral display

  93321 Doppler echo, pulsed wave and/or spectral display, follow-up or limited study

  93325 Doppler echo, color flow velocity mapping

v The Doppler echo codes, if performed, may be reported with TEE codes: 93312, 93314, 93315, and 93317.



  For coding purposes, there are two parts to the TEE service:

1. Placement of the transesophageal probe (transducer)

2. Image acquisition, interpretation, and report



  The complete transesophageal echocardiogram service, including both probe placement and image acquisition/interpretation, is reported with code 93312.

  Probe placement only is reported with code 93313.

  The image acquisition/interpretation only is reported with code 93314.



  Physicians use codes 93312, 93313, and/or 93314 to report professional services if the test is performed in a hospital or other facility where the  physician cannot bill globally.

  Modifier -26 (professional component) is appended to the appropriate code

  Codes 93313 and 93314 should never be billed together.

v If both services are provided, code 93312 is reported.

  Hospitals should report TEE procedures using code 93312 (the complete service).

  Codes 93313 and 93314 are not used for hospital billing.

  Transesophageal echo is frequently used to monitor patients undergoing cardiac surgery and is reported with code 93318.




o The following are indications for which transesophageal echocardiography (TEE) can be performed at least once:

  Limited transthoracic echo window

  Detection of embolic source or intracardiac shunting when TTE is inconclusive

  Examples: atrial septal defect, ventricular septal defect, patent foramen ovale, aortic cholesterol plaques, thrombus in cardiac chambers, valve vegetations, tumor

  Evaluation of embolic events when there is an abnormal TTE, abnormal ECG, and a history of atrial fibrillation

  Need to clarify pathology of the atria/atrial appendage, aorta, mitral/aortic valve beyond the information that other imaging studies have provided



  Evaluation of cardiac valve dysfunction

  Differentiation of tricuspid from bicuspid aortic valve

  Congenital abnormalities

o The need for repeat TEE studies is based upon findings in the original study
and documentation of the way in which repeat studies will affect patient management:

o TEE is not particularly sensitive for left ventricular assessment since this chamber lies farther from the TEE probe than in transthoracic echo

  Exceptions: the base of the heart in evaluating asymmetric septal hypertrophy or membranous ventricular septal defect

Frequency of Echocardiography Testing

o Repeat echocardiograms are no longer supported (annually or otherwise) for evaluation of clinically stable syndromes, including valvular heart disease, evaluation of prosthetic valve, cardiomyopathy, and hypertension.

o Annual testing can be performed for the following when there is evidence for change in clinical status or to assess interventions (medical or surgical):

Ø Assessment of left ventricular hypertrophy progression or regression

Ø Assessment of valve dysfunction

Ø Assessment of cardiac chamber size in cardiomyopathy and atrial dysrhythmias

Ø Assessment of chronic pericardial effusions

Ø Assessment of left ventricular contractility/diastolic function prior to planned medical therapy for heart failure or to evaluate the effectiveness of on-going therapy

§ BNP levels are useful and may alone be sufficient for monitoring in many cases

Ø Assessment of aortic dissection

Ø Assessment of aortic root dilatation

o Testing twice a year should not be routine but can be performed for the
following:

Ø New or changing (not chronic stable) pericardial effusions

Ø Assessment of new/changed medical therapy for congestive heart failure

§ BNP levels are useful and may alone be sufficient for monitoring in many cases

Ø Assessment of new/changed medical therapy for hypertension if left ventricular hypertrophy was present

Ø Assessment of hypertrophic cardiomyopathy when the results of the echo will potentially change patient management

Ø Assessment of critical valvular heart disease when the results of the echo will potentially change patient management

o New Echo can be performed for the following regardless of number of previous Echo studies:

Ø New cardiac murmurs

Ø New myocardial infarction or acute coronary syndrome

Ø New congestive heart failure (or new symptoms of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, elevated BNP)

Ø New pericardial disease

Ø New stroke/transient ischemic attack

Ø New aortic dissection (TEE is preferred)

Ø New decompression illness

Transthoracic Echocardiography (TTE) CPT codes and indication

2011 Transthoracic Echo CPT® Codes:



§ CPT®93303 TTE for congenital cardiac anomalies, complete

§ CPT®93304 TTE for congenital cardiac anomalies, follow-up or limited

§ CPT®93306 TTE with 2-D, M-mode, Doppler and color flow, complete

§ CPT®93307 TTE with 2-D, M-mode, without Doppler or color flow

§ CPT®93308 TTE with 2-D, M-mode, follow-up or limited



The following are indications for which transthoracic echocardiography (TTE) can be performed at least once:

Ø Valve function and structure including:

§ Mitral valve prolapse

§ Mitral regurgitation

§ Mitral stenosis

§ Aortic regurgitation

§ Aortic stenosis

§ Bicuspid aortic valve

§ Tricuspid valve regurgitation

§ Pulmonary valve regurgitation

Ø If valve surgery is being considered, TTE to assess aortic, pulmonary or mitral stenosis or regurgitation can be performed once or twice a year.

§ TTE can accurately assess the severity of valve stenosis but is sometimes less accurate in assessing valve regurgitation.



Ø Ventricular function including global and segmental wall motion for evaluating ejection fraction (EF) and coronary artery disease.

§ Echo can be performed to evaluate cardiomyopathy due to etiologies such as ischemia, alcohol, viral myocarditis, or idiopathic.

§ Echo can be performed before and after chemotherapy known to affect heart function.

Ø Ventricular structure including:

§ Infiltrative diseases (e.g. sarcoid, amyloid)

§ Aneurysm with/without thrombus

§ Ventricular septal defect (VSD)

§ Papillary muscle rupture/dysfunction

§ Hypertrophy (including asymmetric septal hypertrophy, spade heart, hypertensive concentric hypertrophy, infiltrative hypertrophy)

Ø Evaluate atrial or ventricular chamber size (e.g. patients with atrial fibrillation, tachyarrhythmias, or left ventricular dilatation).

§ Yearly TTE may be indicated depending on the clinical circumstance.

Ø Detection of embolic source in patients with recent Transient Ischemic
Attack (TIA), stroke, or peripheral vascular emboli.


§ Although transesophageal Echo (TEE) is more accurate in visualizing thrombus in the cardiac chambers and in visualizing the cardiac valves for vegetations (or classic mitral valve fibrinous excrescences), TTE is non-invasive and is indicated as the initial study.

§ Intravenous injected sterile saline contrast can be performed for shunt detection in cases of known or suspected atrial and/or ventricular septal defect and/or patent foramen ovale.

v This is best assessed using TEE, especially in patients with decompression illness, although TTE is still useful in this setting.

Ø Evaluation of ASD repair or VSD repair; within the first year of surgery, if stable clinically, routine imaging is not supported.

§ If patients become newly symptomatic more than one year after successful repair of congenital heart disease, TTE is appropriate

Ø Tumor evaluation including myxomas

Ø Clot detection

Ø Evaluation of right ventricular systolic pressure and pulmonary
hypertension

Ø Evaluation of pericardial effusion/pericardial disease including pericardial cysts
 (cysts are usually benign, most frequently at the right cardiophrenic border, treated by observation [chest CT, cardiac MRI, or TTE] or drainage  prcutaneously or by open surgery), particularly suspected cardiac tamponade

Ø Evaluation of congenital heart disease

Ø Evaluation of endocarditis

§ TTE or TEE is appropriate when there is fever, positive blood cultures indicating bacteremia, or a new murmur.

v Note: lack of visible vegetations does not eliminate the diagnosis.

v TEE remains a more sensitive technique for identification of small vegetations.

Ø Complications of pacemaker insertion should be monitored by TTE

Ø Coarctation of the Aorta

§ Follow-up (surveillance) imaging after repair of coarctation.

v Infants and children: echo every month for several months, then echo every 6 months to one year thereafter until age 18, then follow surveillance imaging frequency for adults—chest MRA (CPT®71555) every 2 to 3 years and before  and after any intervention for re-coarctation.

o Screening for first-degree relatives of patients with hypertrophic
cardiomyopathy (HCM)

Ø First-degree relatives who are 12 to 18 years old should be screened yearly for HCM by 2D- echocardiography and ECG .

Ø First-degree relatives who are older than age 18 should have 2D-echo and
ECG every five years to screen for delayed adult-onset LVH.

Ø Systematic screening is usually not indicated for first-degree relatives who
are younger than age 12 unless there is a high-risk family history or the child is involved in particularly intense competitive sports.

Ø Affected individuals identified through family screening or otherwise should be evaluated every 12 to18 months with 2D-echo, Holter monitor, and blood pressure response during maximal upright exercise.