Documentation Is Key for TEE and OLV
By Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CANPC, CPC-I, CMRS
A transesophageal echocardiogram (TEE) uses an ultrasound transducer positioned on an endoscope and guided into the patient’s esophagus to visualize the heart’s valves and chambers without interference from the ribs or lungs.
An anesthesiologist may use TEE as a diagnostic tool to establish conditions such as myocardial ischemia or cardiac valve disorders. In such cases, you may bill the TEE separately in addition to the anesthesia. You must append modifier 59 Distinct procedural service to the appropriate TEE code, or National Correct Coding Initiative (NCCI) edits will automatically bundle the TEE with the anesthesia.
You should report TEE using either 93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report for a basic study, or 99315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report for a congenital study. It is important to distinguish between the procedures because reimbursement is higher for a congenital study.
To identify a congenital study, look for documentation stating “congenital,” and/or for a diagnosis of congenital anomalies, such as 745.10 Complete transposition of great vessels.
Apply Modifiers, Add-ons, for Complete Coding
When reporting TEE studies, don’t forget modifier 26 Professional component. This modifier always must be applied in the facility setting, or whenever the anesthesiologist performing the TEE does not own the equipment used to conduct the study. The anesthesiologist must perform the placement, image acquisition, and interpretation (including a written report) to correctly bill for these services.
Add-on codes may also be applicable with TEE, such as those for pulse wave/continuous wave (PW/CW) Doppler (+93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete) or color flow Doppler (+93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)). Doppler procedures may be performed at the request of the surgeon, usually for valve disorder.
Other, additional procedures that may be performed with TEE include 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation, or 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation. Three-dimensional rendering allows for more complete visualization of structures, and may be ordered because of intrathoracic organ abnormalities found in more conventional imaging.
As with the TEE codes, you must append modifier 26 to Doppler and 3D rendering codes when the service is provided in a facility setting (which will most likely be the case), or anytime the billing physician does not own the equipment necessary to provide the service.
Coding Example: The anesthesiologist documents a coronary artery bypass graft (CABG) x 1, along with a basic study TEE with PW/CW, color flow Doppler, and 3D rendering without independent workstation. Proper coding is:
- 00567 Anesthesia for direct coronary artery bypass grafting; with pump oxygenator
- 93312-26-59 for the basic study. Modifiers 59 and 26 are appended to indicate this as a separate procedure, distinct from anesthesia, and that only the professional portion of the service is being billed.
- +93320-26 to describe the PW/CW Doppler. Because +93320 is an add-on code, modifier 59 is not required; however, modifier 26 is required to indicate that the anesthesiologist is providing only the professional portion of the service.
- +93325-26 is reported in addition to 93312 for color flow Doppler, professional component.
TEE for Monitoring Isn’t Separately Reportable
When an anesthesiologist performs a TEE for monitoring purposes only, you will not receive separate reimbursement for the TEE in addition to any anesthesia service provided.
TEE monitoring of ventricular function is used intra-operatively in select high-risk patients and, if performed by the anesthesiologist during surgery, is included in the reimbursement of the anesthesia service. You would not separately report 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.
One Lung Ventilation and VATS
One lung ventilation (OLV)—the ability to ventilate one of a patient’s lungs, allowing the other one to collapse—is used when performing video-assisted thoracic surgery (VATS), lobectomy, or Maze procedures to treat atrial fibrillation, to name a few examples. You’ll want to be sure that your anesthesiologist is properly documenting OLV—and that you, the coder, are able to recognize it in the anesthesia record—because OLV has a higher base value than non-OLV procedures.
For example, 00540 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not otherwise specified is a 12 base, but 00541 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing 1 lung ventilation, which includes OLV, is a 15 base. This three-base difference matters for reimbursement.
Coders should always try to bill directly from the anesthesia record (rather than from a charge voucher, for instance). OLV will most often be documented with a “down arrow” (showing the lung has been deflated), followed by an arrow up when the lung is re-inflated. Because most anesthesiologists won’t write out “OLV,” it’s important for coders to recognize this shorthand documentation.
Understanding when and why other services might be performed by the anesthesiologist will enable you to help your physician document necessary information on the anesthesia record. In return, you will be able to code correctly and your physician will see more reimbursement.
Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CANPC, CPC-I, CMRS, has been coding/billing anesthesia for over 30 years. For the past 19 years she has been the business administrator for Anesthesia Specialists, a group of nine cardiac anesthesiologists at Sentara Heart Hospital. Ms. Wilson started the AAPC Virginia Beach local chapter and is an active member. She teaches medical coding classes in Tidewater, Va. Ms. Wilson has served on the AAPCCA Board of Directors since 2010 and was treasurer in 2011. She has presented at several AAPC regional conferences and the national conference in Las Vegas.