Congenital vs. Non-congenital Echocardiograms: Avoid the Guesswork
By Janice G. Jacobs, CPA, CPC, CPCO, CCS, ROCC
In 1997, the American Medical Association (AMA) added codes to the echocardiology section of the CPT® codebook to further define echocardiograms when performed with a confirmed congenital anomaly. Although the intent was to identify a special situation that does not fall into the normal echocardiology realm, the additions caused confusion for cardiologists and coders in assigning codes for suspected cardiac anomalies.
Proper application of CPT® codes 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete versus 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography has resulted in numerous debates. Coding guidance often appears conflicting, even within the same document.
Set the Record Straight
When a patient presents with a suspected, unconfirmed congenital anomaly and an echocardiogram is performed, many cardiologists believe that the proper code is 93303 because the stated reason for the study is either to confirm or rule out a cardiac anomaly. In actuality, 93303 is only for confirmed anomalies.
A basic rule of thumb is that when a congenital echo is ordered, but a congenital anomaly is not detected, use the regular echo code (93306). If a congenital echo is ordered and a defect is detected, use the congenital code (93303). Conversely, when a regular echocardiogram is ordered and a congenital anomaly is detected, turn to the congenital code (93303).
Support for coding congenital echocardiograms can be found in the AMA’s CPT® Assistant, December 1997, which states, “The Congenital Heart Disease (CHD) codes should not be used when suspected CHD is not confirmed by the echo exam.” The American College of Cardiology also recommends that the congenital heart disease echo codes be used when CHD is known to be present or is detected on the exam. In absence of a CHD diagnosis, report the regular echocardiogram codes.
Complete Vs. Limited
There are additional questions regarding the difference between a complete congenital study and a limited congenital study. A complete congenital study requires an evaluation of the aorta and pericardium, which is often lacking in the clinical documentation. Based on CPT® criteria:
“… a complete transthoracic echocardiogram requires 2-dimensional and, when performed, 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. (Note that while M-mode exam is usually performed, it is not required in order to assign a complete echo code.) If it is impossible to image all of the listed structures, the report must indicate the reason. A limited transthoracic echocardiogram should be billed if the report does not evaluate or attempt to evaluate all of the structures listed above.”
Consider the following examples of proper coding:
- A pediatrician refers a newborn because, upon routine examination, she thought she detected a heart murmur. Your cardiologist performs a congenital echocardiogram, but the results do not reveal a congenital defect. Report the standard echo codes (93306, 93307, 93308, 93312-93314).
- Your cardiologist performs a normal echo on a patient who is not suspected of having CHD; however, upon assessment, it’s discovered the patient has a defect. Regardless of whether the defect is significant enough to warrant treatment, the congenital codes (93303, 93304, 93315-93317) now apply.
- A 15-year-old male patient presents to the cardiologist for a follow-up exam. He was last seen one year ago for an evaluation of a suspected heart murmur due to a positive family history of the same. His primary care physician detected what appeared to be a murmur the previous year. Your cardiologist performs a complete congenital echocardiogram at that time. He does not find any evidence of CHD, but suggests follow up in one year. At this time, a follow-up study for congenital cardiac anomalies is performed, which again shows no evidence of CHD. Your cardiologist documents in the medical record “well male patient.” Report the standard follow-up code 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study.
Always Check Carrier Guidelines
Always check with your Medicare administrative contractors (MACs) and individual payers in your area, as reimbursement guidelines can vary dramatically from one insurance company to another, and each payer may have specific documentation/medical necessity requirements for various services.
Janice G. Jacobs, CPA, CPC, CPCO, CCS, ROCC, is a director at IMA Consulting and has over 25 years of health care and consulting experience. During her consulting career she has worked on numerous ambulatory payment classifications (APCs), diagnosis-related groups (DRGs), physician billing and coding projects, and chargemaster (CDM) reviews and various interim-staffing engagements such as billing office manager and director of compliance at a major west coast academic medical center. Ms. Jacobs owned and managed a full-service, multi-specialty medical billing company. She is a Certified Public Accountant licensed in Pennsylvania, with experience in hospital accounting, auditing, and cost reporting.