Get to the Heart of Echocardiology Coding

By Jim Collins, CPC, CPC-CARDIO, ACS-CA, CHCC
Transthoracic echocardiography is an important tool used to assess the structure and function of the heart. Although the test is non-invasive and introduces virtually no risk to the patient, it provides a wealth of information that frequently alters the course of patient management. Echocardiography is one of the largest sources of profit for most cardiology groups. Due to the frequency of echocardiography testing, and its influence on the bottom line, it is essential to accurately code and document it. Failure to take proactive steps toward correct coding could expose your practice to detrimental liability.
Most echocardiographic studies include three separate tests: two-dimensional (2-D) echocardiography, Doppler interrogation, and color flow study. Each of these tests is separately reported and each generates separate reimbursement.

Use 93307 and 93308 to Reflect 2-D Echocardiography

Ultrasound used to non-invasively visualize the size and movement of heart structures is 2-D echocardiography. A transducer sends millions of sound waves into the patient’s body, at several different angles, every second. Sound waves travel into the chest, bounce off of various cardiac structures, and then travel back to the transducer. Because the sound waves are sent in specific sequences, it is possible to monitor the round trip of each sound wave.
Sound waves reflect differently off various tissues in the body. Based on the way sound waves reflect off anatomic structures, and the “round trip,” duration, the computer can generate a 2-D image of the structure: the heart chambers, the cardiac valves, the aortic root, and the pericardium.
When coding for the 2-D portion of the transthoracic echocardiographic study, there are two codes to choose from. The first option, code 93307 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete, is commonly referred to as a “complete-echo.” The second option, code 93308 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; follow-up or limited study, is commonly referred to as a “limited echo.”
Financially, the difference between the payment rates for complete and limited echocardiograms is considerable. Medicare and most other payers compensate nearly twice as much for a complete echocardiographic study as they do for a limited echocardiographic study.
Prior to 2005, the distinction between complete and limited echocardiographic studies was defined by a small portion of payers. Guidelines in the 2005 CPT^® established a nationwide distinction between these two services. The introductory section to echocardiographic codes states a full echocardiographic study is one that includes “2-dimensional and selected M-mode examination of the left and right atria, left and right ventricles, the aortic, mitral, and tricuspid valves, the pericardium, and adjacent portions of the aorta.” For each of these areas “appropriate measurements are obtained and recorded.”
The documentation standard established in CPT^® is very similar to the “report text” documentation requirements established by Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). ICAEL documentation requirements establish that the interpretative report portion of the echo report must contain each element listed in the CPT^® standard plus the 2-D assessment of the pulmonic valve.

The ICAEL standard further clarifies what specific information should be documented about each of these structures and establishes, “Report text must include comments on the following:

• Left Ventricle (size, global and regional function)
• Right Ventricle (size and global function)
• Right Atrium (size)
• Left Atrium (size)
• Mitral Valve (structure and function)
• Aortic Valve (structure and function)
• Tricuspid Valve (structure and function)
• Pulmonic Valve (structure and function)
• Pericardium
• Aorta

For most echocardiographic studies, if any of the nine anatomic structures required by CPT^® is not specifically documented as being evaluated in the final echocardiographic report, the service should be coded as a limited study (93308), rather than a complete study (93307). CPT^® recognizes it may not be possible to assess each of these structures despite significant effort. For example, sometimes a good acoustic window can’t be obtained because of the shape, structure, or size of the patient’s body. In such circumstances, the report should explain why the missing information could not be obtained. As established in CPT^®, if the report reflects technical difficulties precluding the doctor from assessing each of the above structures, code 93307 is appropriate.
When the doctor performs a follow-up study of the heart at a later date, report code 93308. These follow-up studies usually focus on a specific area of the heart, rather than on the entire heart.

Code Doppler Imaging the Right Way

Doppler imaging is based on an observation made by Christian Johann Doppler in 1842. The concept of the Doppler effect is easily explained with the analogy of waves in the ocean rather than with sound waves. Waves rolling into shore from the ocean move at a fairly constant rate. If a ship moves from the shore out to sea, waves would hit the front of the ship at a certain rate. If the ship was to move from the ocean toward the shore, the waves would make contact with the ship at a much slower rate: in the first example the ship is meeting each wave at the half-way point, in the second example the wave and the ship are moving in the same direction.
In the echo lab, the principal of the Doppler effect applies to sound waves sent into the patient’s body, and then we assess how frequently and forcefully ultrasonic sound waves reflect off individual red blood cells. By measuring variations in the reflected sound waves, clinicians can determine the speed and direction of blood cells in the heart.
Doppler studies assess valvular performance. The cardiac valves should open to facilitate blood flow in the proper direction, and then slam shut to prevent regurgitation (blood flow in the wrong direction). If valves are damaged or calcified, a substantial amount of blood could flow in the wrong direction. By assessing the velocity and direction of blood flow on each side of the cardiac valves, clinicians can assess how much blood is flowing in the wrong direction. This is frequently referenced as quantifying valvular regurgitation. Doppler data allows doctors to estimate blood pressure inside the heart and the cardiac output.
CPT^® contains two codes to report Doppler studies. Similar to echo codes, the Doppler codes are referred to as complete or limited studies. They are:
93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete
93321 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study
Unlike the 2-D echocardiography, CPT^® does not establish the difference between complete and limited Doppler studies. To gain insight regarding this, look at the ICAEL, documentation standard. It establishes, “A complete Doppler study is one that examines every cardiac valve, and the atrial and ventricular septa for antegrade and/or retrograde flow. In addition, a complete Doppler study provides functional hemodynamic data.” While this standard is not officially incorporated into CPT^® instruction, it is probably a safe guideline to follow as there is a high degree of overlap and concurrence between the CPT^® and ICAEL definitions of complete vs. limited 2-D echocardiographic studies.

Go with 93325 for Color Flow

In this assessment, the computer uses data obtained from Doppler waves to label blood cells a certain color based on their travelling direction. Most systems label blood cells moving toward the transducer as red and those moving away from the transducer as blue. By color coding blood cells based on the direction they travel, we can identify the presence and severity of valvular regurgitation illustrated by a contrasting jet of blood flowing in the wrong direction across a valve (a regurgitent jet). Color flow studies also allow clinicians to identify septal defects, areas of stenosis, and the presence of shunts.
A color flow study is a visual assessment of blood flowing through the heart. Unlike 2-D and Doppler studies, the color flow study does not produce numeric measurements. While the ICAEL standard references that “any regurgitation, shown in at least two imaging planes with color Doppler” should be documented, there are no reliable guidelines as to definitive documentation in the report to support the performance and interpretation of the color flow study. It is best to specifically document when a color flow study is performed and provides a brief summary of what is revealed: normal or abnormal.
Unlike the 2-D echocardiography and Doppler studies, there is only one code to report a color flow study: 93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography). There is no distinction between complete and limited color flow studies.

Check the Add-on Status

Because the Doppler and color flow codes are listed as add-on codes in CPT^®, the + symbol is listed next to these codes. CPT^® notes to only report these add-on codes when certain base codes are reported. These restrictions are:
+93320—use in addition to 93303, 93304, 93307, 93308, 93312, 93314, 93315, 93317, or 93350.
+93321—use with the same list as 93320.
+93325—use in addition to the same list, plus 76825, 76826, 76827, 76828, (fetal echo codes) or 93320, 93321.

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