Cardiology Coding Alert

CPT further specifies that you cannot report Doppler codes 93320-93325 without an accompanying echocardiography code.

In echocardiography imaging, ultrasound waves rebound or "echo" off the heart muscle, creating an image of the valves and chambers and showing the flow of blood through the heart.

Doppler echocardiography employs a special microphone that allows technicians to measure and analyze the direction and speed of blood flow through blood vessels and heart valves.

Typically, during echocardiography studies, the cardiologist may need to use pulsed wave and/or continuous wave Doppler with spectral display and/or Doppler color flow velocity mapping, says Cynthia Swanson, RN, CPC, a coding consultant with Seim, Johnson, Sestak and Quist in Omaha, Neb.

The additional testing through Doppler technology can provide further information about a patient's condition or quantity/complexity of the cardiac problem, Swanson says.

For instance, if a patient has a Doppler as part of an echocardiography study, such as two-dimensional echocardiographic imaging (93307, Echocardiography, transthoracic, real-time with image documentation [2-D] with or without M-mode recording; complete), you would add either 93320, 93321 or 93325 to 93307, depending on whether the patient had pulsed wave and/or continuous wave or color flow velocity mapping, Swanson says.

Distinguish Between Waves and Color Flows

Doppler pulsed wave/continuous wave studies and Doppler color flow velocity mapping generate different results, so coders should code the procedures separately.

Code 93320 describes pulsed wave and/or continuous wave Doppler with spectral display. The advantage of the pulsed wave (PW) Doppler is that it calculates blood-flow velocity, direction and spectral characteristics from a specified point in the heart or blood vessel, Swanson says The main disadvantage is that the maximum velocity the cardiologist can measure is limited because the pulse repetition frequency is limited.

Continuous wave (CW) Doppler uses dual crystals so ultrasound waves can be simultaneously and continuously sent and received, Swanson says. There is no maximum measurable velocity with CW, so the physician can measure high-velocity flows. The disadvantage with CW Doppler is that sampling of blood-flow velocity and direction occurs all along the ultrasound beam, not in a specific area.

Code 93325 describes color flow velocity mapping. Color flow mapping is a form of PW Doppler ultrasonography, which combines the M-mode and 2-D modalities with blood flow imaging, according to the American College of Cardiology's (ACC) Guide to CPT 2002.

However, instead of one sample volume, color flow velocity picks up many sample volumes along multiple scan lines, Swanson says. The mean frequency shift the cardiologist obtains from these many sample volumes is color-coded for direction and velocity.

When coding Doppler color flow mapping, check the physician's report to make sure that it indicates the presence of multiple velocities and directions, says Denise White, CPC, a cardiology coding consultant with Acevedo Consulting of Delray Beach, Fla. If the report includes only one velocity, you would not be able bill color flow mapping, she adds.

Diagnosis Codes Added for Dopplers

Cardiologists use PW/CW Doppler spectral display and Doppler color flow mapping to assess a variety of conditions related to abnormalities in valvular function and blood flow, such as endocarditis (424.90), cardiomyopathy (425.x) and congestive heart failure (428.x).

Coders and billers often have problems getting physicians to understand that just because a carrier covers the basic echo for one condition, that does not mean it will cover the Doppler and/or color flow for those same conditions, White says.

Dopplers aren't always covered with basic echocardio-graphy imaging for certain diseases, so you should check with your local Medicare carrier or private payer first.

For instance, Florida's local medical review policy, which is very similar to other states in its general guidelines, covers basic echocardiography and Doppler PW/CW and color flow mapping for transposition of great vessels (745.10 to 745.19), White says. The carrier, however, covers only basic echocardiography for injury to the heart (861.00 to 861.03 and 861.10), she says.

If you encounter a diagnosis that is not on your payer's approved list for Dopplers, you should submit the claim with medical-necessity documentation, says Sheldrian Wayne, CPC, a cardiology coding specialist with Atlanta-based Coding Strategies Inc.

Payers Are Prone to Doppler Bundling

Some carriers do not recognize Dopplers as separate from basic transthoracic (93307) or transesophageal (TEE) echos (93312-93314) and inappropriately bundle payment for Doppler services into reimbursement for the basic echo service, according to the ACC's Guide to CPT 2002.

There are three distinct CPT codes for Dopplers 93320, 93321 and 93325 and you can bill for all three as long as the cardiologist provides each modality and medically supports it with appropriate documentation, White says. Even so, non-Medicare payers are historically known for bundling Doppler procedures with basic echos, she says.

For instance, Blue Cross/Blue Shield (BC/BS) in Michigan started bundling Doppler studies into basic echos, and many other BC/BS carriers are doing the same, says Savanna Siens, CPC, CCS-P, a cardiology coder with Northland Cardiology in Kansas City, Mo. The solution to the problem is to educate insurance companies about Dopplers by explaining the difference between basic and Doppler echocardiography, White and Siens say.

Note: To find out if your local Medicare carrier covers Dopplers, go to www.lmrp.net.