Cardiology Coding Alert

Can’t evaluate all required anatomy? Complete exam code may still be an option.

You may see a boost in echocardiography pay from Medicare in 2014. To be sure your practice gets every dollar earned — now and in the future — follow these 3 tips to cleaner 93306 claims.

Fee news: Medicare’s proposed 2014 fee schedule shows an increase in rates for several echocardiography codes. One of note is 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). The 2013 national rate is roughly $189, but the code may see a payment increase of more than 20 percent in 2014, according to the American Society of Echocardiography (ASE) (www.asecho.org/2013/07/cms-releases-proposes-increased-medicare-payment-for-echocardiography-in-2014/; also see www.cardiosource.org/en/News-Media/Publications/Cardiology-Magazine/2013/07/2014-Medicare-Proposed-Rule-Analysis.aspx).

For 93306, confidently capturing the proper reimbursement depends on watching for documentation of spectral and color Doppler, ensuring the exam is complete, and understanding when congenital echo codes come into play.

1. 93306 vs. 93307: Seek Spectral and Color Doppler Documentation

An important distinguishing characteristic of 93306 is that it requires both spectral and color Doppler. If a transthoracic echo (TTE) service does not include both spectral and color Doppler, you should instead report 93307 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography).

Medicare’s national rate for global 93307 is about $75 less than the 93306 rate, or if you’re reporting just the professional component using modifier 26 (Professional component), the difference is close to $18. So you want to be sure you’re properly distinguishing between these two codes.

Clear documentation is the key. You want to see both "color flow" findings and Doppler measurements, says Jessica Carriveau, CPC, CCC, a coder with Prevea Health in Wisconsin. Color flow mapping assigns colors to the blood flow for better evaluation of abnormal blood flow. Spectral Doppler provides a graphic display with flow velocity on one axis and time on another.

"Both the Doppler and color flow can assess valvular regurgitation (insufficiency) as well as localized obstructions, or shunts," says Carriveau. You can’t make assumptions about which method was used. Wording you may see for color Doppler includes "Color mapping confirms …," while spectral Doppler documentation may be something like "Normal Doppler flow velocities through the individual heart valves," says Carriveau.

2. 93306 vs. 93308: Count Elements for Complete and Limited

Another important element of 93306 is that it qualifies as a complete exam. For a limited exam, you should instead report 93308 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study).

Complete: You can find the requirements for a complete TTE in the CPT® guidelines, says Carriveau:

"A comprehensive procedure that includes 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. Multiple views are required to obtain a complete functional and anatomic evaluation, and appropriate measurements are obtained and recorded." Other structures identified in the same anatomic area are not required, but their evaluation is bundled into 93306 if performed. Examples include pulmonary vessels, the pulmonic valve, and the inferior vena cava.

Opportunity: The guidelines state you also may count an exam as complete when the physician can’t evaluate every structure listed, as long as he documents the attempt to evaluate and explains why a structure couldn’t be visualized.

Limited: A limited TTE "is an examination that does not evaluate or document the attempt to evaluate all the structures that comprise the complete echocardiographic exam," the guidelines state.

With the definition of limited, CPT® again shows that documentation of the attempt to evaluate all structures may support reporting a complete code rather than a limited code, Carriveau points out.

You’re likely to see a 93308 limited study when the physician needs "a focused study performed to evaluate one specific problem or region of the heart," Carriveau says. Examples include following up on a pericardial effusion to see if it has progressed or resolved, or serial evaluation of left ventricular function in a patient undergoing chemotherapy, she adds.

3. 93306 vs 93303-93304: Keep Congenital Rules Straight

One rule for proper 93306 use is easy to miss: You should use non-congenital code 93306 when a congenital anomaly is suspected but not found. CPT® Assistant included this rule as early as December 1997.

Many coders are tempted to use one of these congenital TTE codes when documentation shows the reason for the exam is a suspected congenital anomaly:

• 93303, Transthoracic echocardiography for congenital cardiac anomalies; complete
• 93304, … follow-up or limited study.

But if there is no congenital anomaly found to evaluate, you should use a non-congenital echo code to report the service.