11 - ICD10 SpecialtyTips TEE - abeo€¦ · 11/01/2016 · ICD$10!SPECIALTYTIPS’...

ICD-‐10 SPECIALTY TIPS

Transesophageal Echocardiography (TEE) | 1 of 6

SPECIALTY TIP #11 Transesophageal Echocardiography (TEE)

Ø CPT coding rules state, “Report of an echocardiographic study, whether complete or limited, includes an interpretation of all obtained information, documentation of all clinically relevant findings including quantitative measurements obtained, plus a description of any recognized abnormalities. Pertinent images, videotape, and/or digital data are archived for permanent storage and are available for subsequent review. Use of echocardiography not meeting these criteria is not separately reportable.”

Ø CMS policy for reimbursable indications for intraoperative TEE: “The interpretation of TEE during surgery is covered only when the surgeon or other physician has requested echocardiography for a specific diagnostic reason (e.g., determination of proper valve placement, assessment of the adequacy of valvuloplasty or revascularization, placement of shunts or other devices, assessment of vascular integrity, or detection of intravascular air). To be a covered service, TEE must include a complete interpretation/report by the performing physician. Coverage for evaluation, however, is not allowed for monitoring, technical trouble shooting, or any other purpose that does not meet the medical necessity criteria for the diagnostic test.”

Ø When a TEE is performed by an anesthesiologist for intraoperative monitoring purposes only, the probe placement may not be billed separately as CPT coding conventions do not allow an option for the placement to be separately billed from the total intraoperative monitoring service.

Documentation Requirements

• Documentation from a surgeon or other physician requesting echocardiography for a specific diagnostic reason.

o The rationale for performing the study must be clearly documented in the medical record. o The medical record should indicate this request either by an order in the medical record, the

operative consent form, progress notes, or at the very least within the dictated echocardiography report.

o It should also be clear whether the intraoperative enteroscopy (IOE) was performed for diagnostic, monitoring, or research purposes.

• A complete interpretation and report generated by the echocardiographer. o A final written interpretation of all diagnostic echocardiography studies, including TEE, must be

produced and maintained in the patient’s record. § Diagnostic intraoperative TEE must be documented in the patient’s record with videotape or

another recording technique and the physician must provide a written interpretation. o “At a minimum, a complete study should include (2-‐D with or without M-‐mode) measurements of

left ventricular end diastolic diameter, left ventricular end systolic diameter, left ventricular wall thickness, left atrial diameter, aortic valve excursion, qualitative description of left ventricular function and, as applies, a description of any technical limitations for particular cases. Valid substitutes for the previous parameters may be recorded, such as LV volumes, ejection fraction and LV mass measurements.” Noridian, LCD L26723

o Best practices include submission of a copy of the completed and signed TEE report with the billing sheet.

• The production and retention of image documentation are required for echocardiography codes.



o Permanent images, either electronic or hardcopy must be retained in the patient’s record or some other archive in order to meet the requirements of billing these CPT1 codes.

• TEE should only be performed if it is expected to alter the care of the patient. o Routine use of intraoperative TEE, even in patients undergoing bypass or valvular procedures, is not

covered by most carriers. • Note: If the TEE is performed for diagnostic purposes by the same anesthesiologist who is providing

anesthesia for a separate procedure, modifier 59 should be appended to the TEE code to note that it is distinct and independent from the anesthesia service.

TEE Codes • 93312 -‐ Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-‐mode

recording); including probe placement, image acquisition, interpretation and report describes the entire TEE service when it is performed by a single physician with or without the assistance of a sonographer for image acquisition.

o Used when the patient’s condition, as described under 93312, requires repetitive evaluation of cardiac function in order to guide ongoing management. Requires image documentation and a written interpretation to satisfy the requirements of billing the service and can be used to describe intraoperative and non-‐intraoperative TEE procedures.

o This service involves placement of the transesophageal probe, obtaining the appropriate images and views, and critical analysis of the data.

§ Patients with increased risks of hemodynamic disturbances may require probe insertion and interpretation of the echocardiogram. This includes, but is not limited to, histories of congestive heart failure, severe ischemic heart disease, valvular disease, aortic aneurysm, major trauma and burns.

§ It may also be indicated in certain procedures that involve great shifts in the patient's volume status. Such procedures may include vascular surgery, cardiac surgery, liver resection/transplantation, extensive tumor resections and radical orthopedic surgery.

§ The use of TEE may also be indicated when central venous access is contraindicated or difficult and it is not possible to adequately assess blood loss and replacement, impairment of venous return, and right and left heart function without the TEE.

• *93313 – Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-‐mode recording); Placement of the probe only.

o No modifiers are used with CPT code 93313 for probe placement as this code does not have separate professional and technical components.

• 93314 – Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-‐mode recording); image acquisition, interpretation and report only

o This code is used when one physician inserts the probe (93313) and another interprets the images (93314). This code requires image documentation and a written interpretation to satisfy the requirements of billing the service. The codes can be used to describe intraoperative and non-‐intraoperative TEE procedures.

• *93318 – Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-‐dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis.

o This code is used when the patient’s condition, as described under 93312, requires repetitive evaluation of cardiac function in order to guide ongoing management.

o CPT code 93318 is unique in that no permanent images are created. o CPT code 93318 is a non-‐covered service by the majority of Medicare Carriers. A few carriers provide

coverage of this service for a small group of high-‐risk patients.



• 93355 – (New code for 2015) – Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (e.g. 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 qualitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D

o Some areas of the U.S. are reportedly receiving denials for anesthesiologists if this is performed at the same time anesthesia is being administered. We believe this is because an anesthesiologist cannot properly administer anesthesia with the monitoring required at the same time he/she may need their total attention on the guidance of the TEE.

Congenital Condition Procedures • 93315 – Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image

acquisition, interpretation and report o This service involves placement of the transesophageal probe, obtaining the appropriate images and

views, and critical analysis of the data in patients with congenital cardiac anomalies. § This includes, but is not limited to, congenital valve problems, such as bicuspid aortic valve,

septal defects, including patent foramen ovale, and more complicated congenital heart defects. § This includes, but is not limited to, all the indications listed for code 93312, but in patients with

congenital cardiac anomalies. • 93316 – Placement of transesophageal probe only (for congenital cardiac anomalies)

o This is the equivalent of code 93313, but in patients with congenital cardiac anomalies. • 93317 – Image acquisition, interpretation and report only (for congenital cardiac anomalies)

o This is the equivalent of code 93314, but in patients with congenital cardiac anomalies. Additional Codes if Documented • +93320 – Doppler Echocardiography, pulsed wave and/or continuous wave with spectral display. (List separately

in addition to codes for 2D echocardiographic imaging); complete • +93321 – Follow-‐up or limited study

o To report a quantitative evaluation of flow, CPT codes +93320 and +93321– pulsed and/or continuous wave Doppler – can be reported for complete studies and limited studies respectively. CPT codes +93320 and +93321 are “add-‐on codes” and cannot be reported separately. They may be reported in conjunction with 93312 and 93314, but cannot be reported with codes 93313 or 93318.

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

o To report a color Doppler examination of the flow of blood through the heart’s chambers and valves, report CPT code +93325 in addition to the codes for 2D transesophageal echocardiography. Note that code +93325 is an “add-‐on” code and cannot be reported separately. It can be used in conjunction with 93312 and 93314, but cannot be reported with codes 93313 or 93318.

Diagnosis Under the Medicare program, the physician should select the diagnosis or ICD-‐9 code based upon the test results, with two exceptions.

1. If the test does not yield a diagnosis or was normal, the physician should use the pre-‐service signs, symptoms and conditions that prompted the study.

2. If the test is a screening examination ordered in the absence of any signs or symptoms of illness or injury, the physician should select “screening” as the primary reason for the service and record the test results, if any, as additional diagnoses.



Below are listed SOME of the covered diagnosis for TEE procedures per a Noridian LCD (Local Coverage Determination). There were far too many covered diagnosis to list here. But this helps to illustrate that almost any type of a cardiac condition can medically support the use of TEE. Be sure to include the cardiac condition necessitating the TEE in your documentation. Condition Options

Sepsis Sepsis due to: A40.3 -‐ Streptococcus pneumoniae A41.01 -‐ Methicillin susceptible Staphylococcus aureus A41.1 -‐ other specified staphylococcus A41.2 -‐ unspecified staphylococcus A41.3 -‐ Hemophilus influenzae A41.4 -‐ anaerobes A41.50 -‐ Gram-‐negative sepsis, unspecified

A41.51 -‐ Escherichia coli [E. coli] A41.52 -‐ Pseudomonas A41.53 -‐ Serratia A41.59 -‐ Other Gram-‐negative sepsis A41.89 -‐ Other specified sepsis A41.9 -‐ Sepsis, unspecified organism A40.9 -‐ Streptococcal sepsis, unspecified

Malignant Neoplasm of Heart

C79.89 -‐ Secondary malignant neoplasm of other specified sites C79.9 -‐ Secondary malignant neoplasm of unspecified site D15.1 -‐ Benign neoplasm of heart

D48.7 -‐ Neoplasm of uncertain behavior of other specified sites D48.9 -‐ Neoplasm of uncertain behavior, unspecified D49.89 -‐ Neoplasm of unspecified behavior of other specified sites

Symptoms E86.0 Dehydration E86.1 Hypovolemia E86.9 Volume depletion, unspecified E87.70 Fluid overload, unspecified E87.71 Transfusion associated circulatory overload E87.79 Other fluid overload R06.00 Dyspnea, unspecified R06.02 Shortness of breath R06.09 Other forms of dyspnea R06.3 Periodic breathing R06.83 Snoring R06.89 Other abnormalities of breathing

R07.2 Precordial pain R40.4 Transient alteration of awareness R44.1 Visual hallucinations R48.3 Visual agnosia R50.2 Drug induced fever R50.81 Fever presenting with conditions classified elsewhere R50.82 Postprocedural fever R50.9 Fever, unspecified R57.0 Cardiogenic shock R57.1 Hypovolemic shock R57.8 Other shock R57.9 Shock, unspecified

Syndromes G45.0 Vertebro-‐basilar artery syndrome G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.3 Amaurosis fugax G45.8 Other transient cerebral ischemic attacks and related syndromes

G45.9 Transient cerebral ischemic attack, unspecified G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome

Rheumatic Disorders

I01.0 -‐ Acute rheumatic pericarditis I01.1 -‐ Acute rheumatic endocarditis I01.2 -‐ Acute rheumatic myocarditis I05.0 -‐ Rheumatic mitral stenosis I05.1 -‐ Rheumatic mitral insufficiency I05.2 -‐ Rheumatic mitral stenosis with insufficiency I06.0 -‐ Rheumatic aortic stenosis I06.1 -‐ Rheumatic aortic insufficiency I06.2 -‐ Rheumatic aortic stenosis with insufficiency I06.8 -‐ Other rheumatic aortic valve diseases

I06.9 -‐ Rheumatic aortic valve disease, unspecified I07.0 -‐ Rheumatic tricuspid stenosis I07.1 -‐ Rheumatic tricuspid insufficiency I07.2 -‐ Rheumatic tricuspid stenosis and insufficiency I07.8 -‐ Other rheumatic tricuspid valve diseases I07.9 -‐ Rheumatic tricuspid valve disease, unspecified I08.0 -‐ Rheumatic disorders of both mitral and aortic valves I08.8 -‐ Other rheumatic multiple valve diseases I08.9 -‐ Rheumatic multiple valve disease, unspecified I09.89 -‐ Other specified rheumatic heart diseases

Non-‐rheumatic Conditions

I34.0 -‐ Nonrheumatic mitral (valve) insufficiency I34.1 -‐ Nonrheumatic mitral (valve) prolapse I34.2 -‐ Nonrheumatic mitral (valve) stenosis I34.8 -‐ Other nonrheumatic mitral valve disorders I34.9 -‐ Nonrheumatic mitral valve disorder, unspecified I35.0 -‐ Nonrheumatic aortic (valve) stenosis I35.1 -‐ Nonrheumatic aortic (valve) insufficiency I35.2 -‐ Nonrheumatic aortic (valve) stenosis with insufficiency I35.8 -‐ Other nonrheumatic aortic valve disorders I35.9 -‐ Nonrheumatic aortic valve disorder, unspecified

I36.0 -‐ Nonrheumatic tricuspid (valve) stenosis I36.1 -‐ Nonrheumatic tricuspid (valve) insufficiency I36.2 -‐ Nonrheumatic tricuspid (valve) stenosis with insufficiency I36.8 -‐ Other nonrheumatic tricuspid valve disorders I36.9 -‐ Nonrheumatic tricuspid valve disorder, unspecified I37.0 -‐ Nonrheumatic pulmonary valve stenosis I37.1 -‐ Nonrheumatic pulmonary valve insufficiency I37.2 -‐ Nonrheumatic pulmonary valve stenosis with insufficiency I37.8 -‐ Other nonrheumatic pulmonary valve disorders



I37.9 -‐ Nonrheumatic pulmonary valve disorder, unspecified STEMI I21.01 -‐ ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02 -‐ ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 -‐ ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 -‐ ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 -‐ ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 -‐ ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 -‐ ST elevation (STEMI) myocardial infarction involving other sites I21.3 -‐ ST elevation (STEMI) myocardial infarction of unspecified site I21.4 -‐ Non-‐ST elevation (NSTEMI) myocardial infarction I22.0 -‐ Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 -‐ Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I22.2 -‐ Subsequent non-‐ST elevation (NSTEMI) myocardial infarction I22.8 -‐ Subsequent ST elevation (STEMI) myocardial infarction of other sites I22.9 -‐ Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

Complications Following an MI

I23.1 -‐ Atrial septal defect as current complication following acute myocardial infarction I23.2 -‐ Ventricular septal defect as current complication following acute myocardial infarction I23.4 -‐ Rupture of chordae tendineae as current complication following acute myocardial infarction I23.5 -‐ Rupture of papillary muscle as current complication following acute myocardial infarction

Arrythmias I48.0 -‐ Paroxysmal atrial fibrillation I48.1 -‐ Persistent atrial fibrillation I48.2 -‐ Chronic atrial fibrillation I48.3 -‐ Typical atrial flutter

I48.4 -‐ Atypical atrial flutter I48.91 -‐ Unspecified atrial fibrillation I48.92 -‐ Unspecified atrial flutter

Cerebral Infarctions

I63.011/12/19 -‐ Cerebral infarction due to thrombosis of right, left, unspecified vertebral artery I63.02 -‐ Cerebral infarction due to thrombosis of basilar artery I63.031/32/39 -‐ Cerebral infarction due to thrombosis of right, left, unspecified carotid artery I63.09 -‐ Cerebral infarction due to thrombosis of other precerebral artery I63.111/12/19 -‐ Cerebral infarction due to embolism of right, left, unspecified vertebral artery I63.12 -‐ Cerebral infarction due to embolism of basilar artery I63.131/32/39 -‐ Cerebral infarction due to embolism of right, left, unspecified carotid artery I63.19 -‐ Cerebral infarction due to embolism of other precerebral artery I63.211/12/19 -‐ Cerebral infarction due to unspecified occlusion or stenosis of right, left, unspecified vertebral arteries I63.22 -‐ Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries I63.231/32/39 -‐ Cerebral infarction due to unspecified occlusion or stenosis of right, left, unspecified carotid arteries I63.40 -‐ Cerebral infarction due to embolism of unspecified cerebral artery I63.411/12/19 -‐ Cerebral infarction due to embolism of right, left, unspecified middle cerebral artery I63.421/22/29 -‐ Cerebral infarction due to embolism of right, left, unspecified anterior cerebral artery I63.431/32/39 -‐ Cerebral infarction due to embolism of right, left, unspecified posterior cerebral artery I63.441/42/49 -‐ Cerebral infarction due to embolism of right, left, unspecified cerebellar artery I63.49 -‐ Cerebral infarction due to embolism of other cerebral artery I63.50 -‐ Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I63.511/12/19 -‐ Cerebral infarction due to unspecified occlusion or stenosis of right, left, unspecified middle cerebral artery I63.521/22/29 -‐ Cerebral infarction due to unspecified occlusion or stenosis of right, left, unspecified anterior cerebral artery I63.531/32/39 -‐ Cerebral infarction due to unspecified occlusion or stenosis of right, left, unspecified posterior cerebral artery I63.541/42/49 -‐ Cerebral infarction due to unspecified occlusion or stenosis of right, left, unspecified cerebellar artery I63.59 -‐ Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery I63.8 -‐ Other cerebral infarction I63.9 -‐ Cerebral infarction, unspecified

Complications Codes

T79.4XXA Traumatic shock, initial encounter T80.0XXA Air embolism following infusion, transfusion and therapeutic injection, initial encounter T80.211A Bloodstream infection due to central venous catheter, initial encounter T80.212A Local infection due to central venous catheter, initial encounter T80.218A Other infection due to central venous catheter, initial encounter T80.219A Unspecified infection due to central venous catheter, initial encounter

T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter T82.120A Displacement of cardiac electrode, initial encounter T82.121A Displacement of cardiac pulse generator (battery), initial encounter T82.128A Displacement of other cardiac electronic device, initial encounter T82.129A Displacement of unspecified cardiac electronic device, initial encounter T82.190A Other mechanical complication of cardiac



T80.22XA Acute infection following transfusion, infusion, or injection of blood and blood products, initial encounter T81.10XA Postprocedural shock unspecified, initial encounter T81.11XA Postprocedural cardiogenic shock, initial encounter T81.12XA Postprocedural septic shock, initial encounter T81.19XA Other postprocedural shock, initial encounter T81.4XXA Infection following a procedure, initial encounter T81.718A Complication of other artery following a procedure, not elsewhere classified, initial encounter T81.72XA Complication of vein following a procedure, not elsewhere classified, initial encounter T82.01XA Breakdown (mechanical) of heart valve prosthesis, initial encounter T82.02XA Displacement of heart valve prosthesis, initial encounter T82.03XA Leakage of heart valve prosthesis, initial encounter T82.09XA Other mechanical complication of heart valve prosthesis, initial encounter T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter

electrode, initial encounter T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter T82.198A Other mechanical complication of other cardiac electronic device, initial encounter T82.199A Other mechanical complication of unspecified cardiac device, initial encounter T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial encounter T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial encounter T82.827A Fibrosis of cardiac prosthetic devices, implants and grafts, initial encounter T82.837A Hemorrhage of cardiac prosthetic devices, implants and grafts, initial encounter T82.847A Pain from cardiac prosthetic devices, implants and grafts, initial encounter T82.857A Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter T82.867A Thrombosis of cardiac prosthetic devices, implants and grafts, initial encounter T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter

Status Codes Z86.74 -‐ Personal history of sudden cardiac arrest Z94.1 -‐ Heart transplant status Z94.2 -‐ Lung transplant status Z95.2 -‐ Presence of prosthetic heart valve Z95.3 -‐ Presence of xenogenic heart valve Z95.4 -‐ Presence of other heart-‐valve replacement Z98.89 -‐ Other specified postprocedural states

The information provided is only intended to be a general summary and not intended to take place of either written law or regulations.

11 - ICD10 SpecialtyTips TEE - abeo€¦ · 11/01/2016 · ICD$10!SPECIALTYTIPS’...

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