Wiki Surgical TEE not getting paid

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Our anesthesiologists do a surgical TEE for the cardiologists when they are replacing Mitral or Aortic valves and also CABGs. 93312-59 is being denied 90% by all payers. 93355-59 (which I believe is the better code) is also being denied.
Medicare Remark code is CO-236: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination that was provided on the same day . I've reviewed LCDs and still don't know what it is bundling with or is there another modifier that should be used. Please see TEE note below. I just wonder if anyone else has this issue and/or can explain how bill to get reimbursement for this code. Thank you.

Example billing:
33405 (anesthesia time billing) for Aortic valve replacement
36620 (surgical)
93355-59 (surgical)
On a separate claim we bill Central Venous Line
36556-59 (surgical)
76937-26 (radiological)

Procedure Performed: TEE

Preanesthesia Checklist: Patient identified, IV assessed, risks and benefits discussed, monitors and equipment assessed, procedure being performed at surgeon's request and anesthesia consent obtained.

General Procedure Information Diagnostic Indications for Echo: assessment of surgical repair, hemodynamic monitoring and assessment of valve function Physician Requesting Echo:
Location performed: OR Intubated Bite block placed Heart visualized Probe Insertion: Easy Probe Type: 3D and mulitplane Modalities: 3D, color flow mapping, pulse wave Doppler and continuous wave Doppler Echocardiographic and Doppler Measurements

Ventricles Right Ventricle: Cavity size normal. Hypertrophy not present. Thrombus not present. Global function normal. Left Ventricle:Cavity size normal. Hypertrophy present. Thrombus not present. Global Function normal. Ejection Fraction 60%. Other Ventricular Findings: Septal knob 1.28 cm Ventricular Regional Function: 1- Basal Anteroseptal: normal 2- Basal Anterior: normal 3- Basal Anterolateral: normal 4- Basal Inferolateral: normal 5- Basal Inferior: normal 6- Basal Inferoseptal: normal 7- Mid Anteroseptal: normal 8- Mid Anterior: normal 9- Mid Anterolateral: normal 10- Mid Inferolateral: normal 11- Mid Inferior: normal 12- Mid Inferoseptal: normal 13- Apical Anterior: normal 14- Apical Lateral: normal 15- Apical Inferior: normal 16- Apical Septal: normal 17- Apex: normal

Valves Aortic Valve: Annulus normal. Stenosis not present. Regurgitation none. Leaflets normal. Leaflet motions normal. Mitral Valve: Annulus normal. Stenosis not present. Regurgitation mild. Leaflets normal. Leaflet motions normal. Tricuspid Valve: Annulus normal. Stenosis not present. Regurgitation none. Leaflets normal. Leaflet motions normal. Pulmonic Valve: Annulus normal. Stenosis not present. Regurgitation mild. Other Valve Findings: Trace AI and MR central jet. Mild PI Potential exists for SAM AML 2.95 PML 1.6, C-sept 1.78 No gradient in LVOT nor turbulence in outflow tract.

Aorta Ascending Aorta: Size normal. Dissection not present. Aortic Arch: Size normal. Dissection not present. Descending Aorta: Size normal. Dissection not present.

Right Atrium: Size normal. Spontaneous echo contrast not present. Thrombus not present. Tumor not present. Device not present. Left Atrium: Size normal. Spontaneous echo contrast not present. Thrombus not present. Tumor not present. Device not present. Left atrial appendage normal.

Septa Atrial Septum: Intra-atrial septal morphology normal and lipomatous hypertrophy. Ventricular Septum: Intra-ventricular septum morphology normal.

Diastolic Function Measurements: Diastolic Dysfunction Grade= II (Pseudonormal) E= ms A= ms E/A Ratio= DT= ms S/D= IVRT= Other Findings Pericardium: normal Pleural Effusion: none Pulmonary Arteries: normal Pulmonary Venous Flow: normal Anesthesia Information Performed Personally Anesthesiologist: Echocardiogram Comments: No difficulty with probe insertion or manipulation. Prebypass: LVH. Normal RV function and size. No WMA. Valves as above with potential for SAM. No gradient or turbulence in LVOT. Postbypass: Normal rv and lv function. Valves unchanged. No gradient in LVOT. Aortic repair intact.
 
Per NCCI, echocardiography is considered integral to anesthesia services. 93312 should be allowed with a modifier 59 if it meets the specified criteria (not sure why you're seeing this deny, but it could be because you need a modifier 26 also since the technical component is part of the facility claim), but 93555 is bundled to anesthesia services performed as part of an intervention and can't be overridden with a modifier - this should not be billed separately. (And this isn't my specialty, but I think you are incorrect in using this code with 33405 because that is an open valve replacement procedure and 93555 is specifically for a transcatheter procedure.)

See the instructions in Chapter 2 of the NCCI Policy Manual for Medicare Services:

Examples of integral services include, but are not limited to, the following:
  • 93312-93317 (Transesophageal echocardiography when used for monitoring purposes) However, when performed for diagnostic purposes with documentation including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service.
  • 93355 (Transesophageal echocardiography for guidance for transcatheter intracardiac or great vessel(s) structural intervention(s))
 
Per NCCI, echocardiography is considered integral to anesthesia services. 93312 should be allowed with a modifier 59 if it meets the specified criteria (not sure why you're seeing this deny, but it could be because you need a modifier 26 also since the technical component is part of the facility claim), but 93555 is bundled to anesthesia services performed as part of an intervention and can't be overridden with a modifier - this should not be billed separately. (And this isn't my specialty, but I think you are incorrect in using this code with 33405 because that is an open valve replacement procedure and 93555 is specifically for a transcatheter procedure.)

See the instructions in Chapter 2 of the NCCI Policy Manual for Medicare Services:

Examples of integral services include, but are not limited to, the following:
  • 93312-93317 (Transesophageal echocardiography when used for monitoring purposes) However, when performed for diagnostic purposes with documentation including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service.
  • 93355 (Transesophageal echocardiography for guidance for transcatheter intracardiac or great vessel(s) structural intervention(s))
I will review NCCI policy again and use 93312-26. Thank you.
 
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