Cardiology Coding Alert


Confused by Reporting Requirements for TTEs? Read This

Don't forget: There are specific codes for congenital anomalies.

Did you know that the acronyms for two completely different kinds of echocardiograms, transthoracic echocardiograms (TTEs) and transesophageal echocardiograms (TEEs), look eerily similar at first glance?

Don't mix up these acronyms and cause your cardiology practice precious dollars. Read on to learn more about TTEs and sidestep potential confusion when reporting echoes.

Editor's note: Stay tuned next month as we delve into a second type of echocardiography - TEEs.

Discover TTE Codes to Hone Echo Reporting Skills

TTE defined: A TTE, a non-invasive test, is the most common type of echo. During this procedure, the cardiologist places a transducer on the patient's chest, and it transmits high-frequency sound waves. These sound waves bounce off the heart's structures, which produce images and sounds the cardiologist can use to detect heart damage and disease.

When the cardiologist performs a non-stress TTE for reasons other than congenital heart disease, turn to the following codes:

  • 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).
  • 93307 (... without spectral or color Doppler echocardiography).
  • 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study). Note: "A follow up or limited echocardiogram study 93308 is an examination that does not evaluate or document the attempt to evaluate all structures that comprise the complete echocardiographic exam," says Rebecca Sanzone, CPC, CPMA, compliance administrator at St. Vincent Medical Group/Ascension Health in Indianapolis, Indiana. "This is typically limited to, or performed in follow up of a focused clinical concern."

93306: Coders should report 93306 when the documentation supports that a complete transthoracic echocardiogram with spectral Doppler and color flow Doppler was performed in addition to 2D and selected M-mode examination (when performed), says Theresa Dix, CCS-P, CPMA, CCC, ICDCT-CM, coder/auditor of East Tennessee Heart Consultants in Knoxville, Tennessee.

"Transthoracic echo code 93306 is the 'comprehensive' code to report performance and interpretation of all typical views of 2D and M-mode (if done) echo (including apical 4 chamber, subcostal, left parasternal long axis, apical 2 chamber, left ventricular short axis, and aortic valve short axis views," adds Ray Cathey, PA, FAAPA, MHS, MHA, CCS-P, CMSCS, CHCI, CHCC, president of Medical Management Dimensions in Stockton, California. "Suprasternal notch may be necessary in some patients plus performance and interpretation of a spectral Doppler and a color-flow Doppler."

Documentation requirements: To report 93306, the documentation needs to mention certain structures of the heart and their findings, Dix explains. These structures are the left and right atria, left and right ventricles, the aortic, mitral and tricuspid valves, the pericardium, and the adjacent portions of the aorta.

The documentation must also include that the cardiologist performed Doppler/color flow and the findings. Details about the intra cardiac blood flow and hemodynamics would be key, Dix says.

Examples of spectral Doppler is "velocity" and Doppler color flow is "regurgitation," according to Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC's Certified Cardiology Coder steering committee.

"When velocity and regurgitation are mentioned within the documentation, you know Doppler spectral (+93320) and Doppler color flow (+93325) were performed, which are included within the complete component CPT® code 93306," Neighbors adds.

When reporting 93306, you should document the measurements obtained from the various views of the heart as well as interpretation of those various measurements, including mention that a given value is normal or abnormal, an interpretation of what the abnormal values indicate, not just mentioning abnormal values, according to Cathey.

"Normal or abnormal wall motion should be documented," Cathey adds. "Spectral Doppler and color flow Doppler interpretation should be mentioned even if the measurements are normal."

93307: On the other hand, report 93307 when only performing/interpreting the 2D and M-mode echo (if done) without performing the spectral and color flow Dopplers, Cathey says.

Documentation requirements: To report 93307, you must have the same documentation details as when reporting 93306, except there would be nothing about Doppler/color flow, Dix says.

"With 93307, again, the measurements obtained from the various views of the heart should be documented, including the physician's interpretation of those values being either normal or abnormal and, of course an interpretation of what the abnormal values indicate," Cathey adds.

Check Out These TTE Codes for Congenital Anomalies

Two codes specifically describe TTE for congenital anomalies: 93303 (Transthoracic echocardiography for congenital cardiac anomalies; complete) and 93304 (... follow-up or limited study).

Cardiologists use TTE on children and young adults to obtain accurate anatomic definition of most congenital heart diseases. TTE can sometimes prevent the need for preoperative catheterization.

You should report93303when the cardiologist performs a complete echocardiogram on a patient to assess septal defects or other cardiac congenital anomalies.

Caution: "Codes 93303 and 93304 should not be used when complex congenital heart disease is suspected but not found on echocardiographic evaluation or for 'simple' congenital anomalies such as patent foramen ovale (PFO) or bicuspid aortic valve," according to CPT® Assistant Vol. 25, No. 5. "In these cases, the non-congenital echocardiography codes (93306-93308) should be used."

Untangle Options for Stress Echoes Performed With Stress Tests

In some cases, the cardiologist will perform a stress echo along with the stress test. With a stress echo, the cardiologist takes echocardiographic images of the left heart before, after, and sometimes during the stress test to monitor the motion and thickening of specific walls, according to CPT®  Assistant.

Your stress echo code choices are as follows:

  • 93350 (Echocardiography, transthoracic, real-time with image documentation (2D), includes » M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report)
  • 93351 (...including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional).

When the cardiologist performs a stress echocardiogram with a complete cardiovascular stress test (continuous electrocardiographic monitoring, supervision, interpretation, and report), then you would report 93351, according to CPT® guidelines.

If the same cardiologist performs only the professional components of the complete stress test and stress echocardiogram, then you should report 93351 and append modifier 26 (Professional component), according to CPT® guidelines.

Don't miss: "When all professional services of a stress test are not performed by the same physician performing the stress echocardiogram, use 93350 in conjunction with the appropriate codes 93016 (Cardiovascular stresstest using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; supervision only, without interpretation and report) through 93018 (... interpretation and report only) for the components of the cardiovascular stress test that are provided," CPT® adds.

Echocardiographic contrast agent: You would report +93352 (Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure)) for the administration of an echocardiographic contrast agent used in conjunction with 93350 and 93351. Example: Definity (Perflutren Lipid Microsphere).

You should never report +93352 more than once per stress echocardiogram, according to CPT®.