CPT CODE 93306 - 93303, 93307, 93308, 93350, 93325 - Echocardiograms procedure

Medicare changed CPT Code for Echocardiogram and cut reimbursement by 15%


93303 - Transthoracic echocardiography for congenital cardiac anomalies; complete

93304 - Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study - Average fee amount - $130 $150

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  Average fee amount - $210 -  $250

93307 - Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, 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

93320 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete

93321 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)

93325 - Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)

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 - 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

93352 - Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure)


Echocardiograms

Echocardiography uses high frequency sound waves to record the structure of the heart and blood flow within the heart. Transthoracic echocardiograms (TTE) are the most common type of echo performed. During TTE a transducer is moved on the surface of a patient’s chest to obtain images that are captured for analysis. EKG monitoring is also performed to assist in evaluating the heart in different stages of cardiac cycle. Heart chamber size, contraction, wall motion, wall thickness and valve structure can all be evaluated using echocardiography. Doppler echocardiography is often used to detect acute complications following a myocardial infarction.

Doppler color flow imaging evaluates the blood flow through the heart and displays flow data on 2-D echocardiographic image. Doppler wave form imaging provides directional information about flow, velocity and characteristics. Wave form is obtained when a transducer transmits a series of pulses to detect motion.

To report TTE:

93303–Transthoracic Echocardiography for congenital anomalies; complete

93304 – follow-up or limited study

*Please note codes 93303-93304 are to be used for patients with congenital anomalies only

93306-Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler and color flow Doppler echocardiography (93320 and 93325 are now bundled with this code and should not be reported separately)

93307–Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral Doppler or color flow Doppler echocardiography 93308-follow-up or limited study

+ 93320 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display.

+ 93321 - follow-up or limited study

+ 93325 - Doppler echocardiography color flow velocity mapping


Medicare now has a combined CPT Code for Echocardiograms 93306 to replace the combined codes of 93307, 93320 & 93325. The 93306 reimbursement is 15% less than the combined three codes:

93325 - Doppler echocardiography color flow velocity mapping

e.g. Michigan Region 1:  


Billing and Coding Guidelines

What cardiac procedures will require prior authorization?

A Prior authorization is required for the following CPT codes: Diagnostic Catheterization

• CPT codes: 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461 Electrophysiology Implants

• Pacemaker Implant CPT codes: 33206, 33207, 33208, 33212, 33213, 33214, 33227, 33228

• CRT (Cardiac Resynchronization Therapy) CPT device codes: 33221, 33224, 33229, 33231, 33264, CPT Lead 33225

• Defibrillator (AICD) Implant CPT codes: 33230, 33240, 33249, 33262, 33263


Echocardiogram

• CPT codes: 93303, 93304, 93306, 93307, 93308



 Hospital Outpatient

Medicare does not separately reimburse for 3D (76376/76377) for hospital outpatients. Rather, the payment is bundled into the base procedure. However, it is important that hospitals continue to establish charges and report these procedures to maintain accurate future rate-setting by Medicare. In addition, the reporting of these services is necessary for maintaining reimbursement with private payers (who may separately reimburse).Note 3D codes are reported in addition to the primary
echocardiography procedure code (e.g., 93306)


    Limitations

    Echocardiographic studies that are not reasonable and necessary to obtain clinically significant diagnostic or monitoring information are not indicated. The carrier will utilize the American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines (Class III) indications as a reference for such determinations.


Coding Information

1. Submission should include an ICD-9-CMcode as listed in the "ICD-9-CM Codes that Support Medical Necessity" and incorporate secondary diagnosis as instructed by ICD-9- CM.

2. Submissions with an ICD-9-CM code other that those in "ICD-9-CM Codes that Support Medical Necessity" will be denied.

3. National Correct Coding Initiative guidelines should be followed.

4. It is medically inappropriate, and contradicts CPT descriptors, to submit CPT 93306, 93307 or 93308, preformed in conjunction with CPT 93350, as 93350 includes a 93306, 93307 or 93308 service.

5. CPT codes 93014, 93041, 93306, 93307 and 93308 should not be submitted on the same date of service. These are inclusive and do not represent independently identifiable services on a common date of service.

6. All diagnosis should be coded to the highest level of specificity.

7. Clinical scenarios deviating from those outlined in "Indications and Limitations of Coverage and/or Medical Necessity" will be denied.

8. Claims with inadequate medical necessity documentation will be denied on review.

9. Examination frequency exceeding those outlined in "Indications and Limitations of Coverage and/or Medical Necessity" when contemporaneous medical records inadequately support medical necessity, will be denied on review.

10. Screening and/or routine interval examinations will be denied.

11. Examinations performed in close proximity to, or alternating with diagnostic testing providing analogous information, e.g., nuclear medicine studies, MRI and CT, will be denied on review. Patterns suggesting parallel or alternating testing will be subject to medical necessity review.

12. Submissions at variance with conditionals enumerated in "Coding Guidelines" and  "Documentation Requirements" will be denied on review.

13. Submit services for the contrast material on the same claim or on the same date of service as the echocardiogram.

14. If using Q9955, Q9956, Q9957 or A9700 (supply of injectable contrast material for use in echocardiography, per study) identify the contrast agent in the narrative record of the electronic format. List the name of the contrast imaging agent, route of administration and dosage.

15. I.V. contrast agents are not indicated for all patients undergoing echocardiogram. Overutilization will be monitored.

16. Claims for contrast echocardiography must be supported by documentation that conventional studies were inconclusive and that there was a need for the contrast
enhancement.

17. Stress echocardiography when performed as the only procedure should be reported using 93350 (C8928 for OPPS billing).

18. Effective 01/01/2009, when a stress echocardiography test is performed with continuous electrocardiographic monitoring, physician supervision, interpretation and report by the same physician, then the procedure should be reported using CPT code 93351 (C8930 for OPPS, with or without contrast).

19. Use CPT code 93352 to report the administration of contrast with a stress echocardiogram. (CPT codes 93350 or 93351) for Carrier or Part B claims only.


Old reimbursement 
93307 = $192.16;
93320 = $85.40;
93325 = $63.13.
Total: $340.69

New reimbursement: 

93306 = $289.69.

This is a cut of $51.00.



Noncovered

Medicare does not cover echocardiograms performed with equipment that provides limited evaluations. Such evaluations typically do not provide a permanent image and complete interpretation is not performed. These tests have demonstrated value in screening-type evaluations, although they are then considered part of the physician’s exam, similar to a blood-pressure measurement.

Echocardiography performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor as having a positive family history, e.g., familial history of Marfan’s disease). Screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When a screening test is performed, use the appropriate screening ICD-10 code to indicate the test is being done for screening purposes. When the result of the test is abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition. Symptoms or an existing condition must be present to meet medical necessity.

Diagnostic injection services are an integral part of a contrast procedure and are not separately payable.

Q: When performing an echocardiogram for congenital heart defects we use these codes 93303, 93320 and 99325. If the study reveals a normal cardiac structure does the code have to be changed to 93306?

Codes 93303-93304 and 93315-93317 should not be used when congenital heart disease is suspected but not found during echocardiographic evaluation. In such circumstances, the non-congenital echocardiography codes should be reported. (CPT Assistant, August 2013)


Q: Why does the new bundled code 93306 pay much less thna the old code with 93307, 93320 and 93325?

Payment is based on the Relative Value Units (RVU) assigned to the code. The current national Medicare  payment for 93306 is $229 physician office, $427 HOPD. The current National Medicare payment for 93307 + 93320 + 93325 is $213 physician office, $427 HOPD.

Q: When performing an echocardiogram for congenital heart defects we use these codes 93303, 93320 and 99325. If the study reveals a normal cardiac structure does the code have to be changed to 93306?

Codes 93303-93304 and 93315-93317 should not be used when congenital heart disease is suspected but  not found during echocardiographic evaluation. In such circumstances, the non-congenital echocardiography codes should be reported. (CPT Assistant, August 2013)


Q: I perform a pediatric echo study for a child with a murmur, but is there a way to bill for the  congenital study performed as the 93303, 03320 and 93320 code, even if the final diagnosis is only a murmur and on heart defect was detected?

Codes 93303-93304 and 93315-93317 should not be used when congenital heart disease is suspected but not found during echocardiographic evaluation. In such circumstances, the non-congenital echocardiography codes should be reported.


CPT codes 93014, 93041, 93306, 93307 and 93308 should not be submitted on the same date of service. These are inclusive and do not represent independently identifiable services on a common date of service



Q: Can you please speak about reimbursement for 3D Echo, both TEE and TTE. Is there additional reimbursement for it being performed?

Physician

 3D codes 76376 and 76377 are paid under the Medicare Part B Physician fee schedule. As such, the services are eligible for payment. Other payers may also separately reimburse.



Indications and Limitations of Coverage and/or Medical Necessity

The clinical use of contrast echocardiography is appropriate in selected patients to:

Evaluate myocardial ischemia

Quantify myocardial perfusion during stress

Identify the “area at risk” during acute myocardial infarction

Determine the success of reperfusion interventions

Assess myocardial viability


The plethora of structural and functional information provided by TTE is unique among diagnostic testing modalities. The rapid and noninvasive acquisition of this information has contributed to exponential application, and to potential over utilization. This policy addresses the medically necessary and appropriate application of TTE. 

Transesophageal echocardiography (TEE) is the subject of a separate policy statement.

A. Ventricular Function and Cardiomyopathies

Changes in myocardial thickness (hypertrophy and thinning) in derived parameters of contractility, and in chamber volume and morphology, can be quantitated and charted over time by TTE. Cardiac responses to volume perturbations, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional perturbations to a clinical presentation is facilitated. TTE aids in the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. Without clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to repeat TTE assessments more frequently than annually, unless done to evaluate the response to therapeutic intervention.

Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings are not well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of diastolic functional abnormalities. Because the TTE findings suggesting diastolic dysfunction are less well established, when this application of TTE is the primary indication for the test, it will be expected to be performed by examiners recognized as experts in assessment and treatment of ventricular diastolic dysfunction.

Evaluation of diastolic filling parameters by Doppler echocardiography is being used to help establish the prognosis in patients with congestive heart failure and systolic dysfunction as well as to evaluate appropriate parameters of medical treatment.

B. Hypertensive Cardiovascular Disease

When there are no signs or symptoms of heart disease, the use of TTE is not covered for hypertension. Hypertension with clinical evidence of heart disease is a Medicare-covered indication for TTE evaluation. Left ventricular hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. Certain anti-hypertensive medications have been reported to stabilize and possibly contribute to the regression of LVH. The decision to commit certain individuals with insidiously progressive borderline hypertension to long-term anti-hypertensive therapy may be determined by the presence of LVH. TTE may assist in the decision to treat through the formulation and analysis of a treatment program. Baseline TTE and serial annual assessments may be medically appropriate. More frequent assessments should have explicit contemporaneous medical necessity documentation.

C. Acute Myocardial Infarction and Coronary Insufficiency

TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening perturbations and mural thinning can be quantitated and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (e.g., mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. In the setting of acute infarction, repeat study will typically be dictated by the clinical course. If available, the use of contrast agents may improve diagnostic efficiency, and eliminate the need for additional radionuclide testing. Without clinical deterioration or unclear examination findings, repeat assessment is typically performed at discharge. The medical record must document the medical necessity of more frequent TTE assessments.

The role of TTE in the emergency room assessment of individuals presenting with chest pain is not defined at this time. This use is not accepted as a standard-of-care. For TTE to be allowed, clinical findings supporting myocardial dysfunction must be present. When these findings are not present, this use is not covered.

D. Exposure to Cardiotoxic Agents (chemotherapeutic and external)

Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. Baseline assessment, bimonthly during and at six (6) months following therapy, is generally considered medically appropriate for exposure to many cardiotoxic agents. Following accidental exposure to known myocardial toxic agents, without abrupt change in clinical signs and/or symptoms, and when cardiac damage has been identified, annual assessment may be considered reasonable and necessary.

E. Cardiac Transplant and Rejection Monitoring

TTE is an integral part of the cardiac donor-selection and donor-recipient matching process. Evaluation focuses on analysis of ventricular function and valvular integrity. TTE is also incorporated into the management of allograft recipients. Myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics, and the late development of pericardial fluid may alert the clinician to a rejection episode. None of these findings has achieved diagnostic sensitivity or specificity. Typically, TTE is performed weekly for the first four to eight (4-8) weeks following transplant, with decreasing frequency over time. Without acute rejection episodes, approximately two (2) TTE examinations are typically performed yearly in chronic transplant recipients. TTE of cardiac allografts is appropriately performed serially at transplant centers by examiners with expertise in the management of cardiac allograft recipients. Uses in excess of the generally accepted frequency will be expected to have appropriate medical necessity documentation provided.

F. Native Valvular Heart Disease

Detection of mitral stenosis was among the first practical clinical applications of TTE. TTE is well established as the technique of choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of multi-valve pathologies can be quantified. Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist, especially interventions for mitral stenosis. Absent acute intervention, or a discrete change in otherwise stable clinical signs and symptoms, TTE is used annually in follow-up of chronic valvular disease to document the course over time. Generally, it is not medically necessary to repeat these examinations more frequently than annually. When the patient’s plan of care includes imminent valvular surgery, more frequent exams may be necessary.

G. Prosthetic Heart Valves (Mechanical & Bio-prostheses)

TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile. Reassessment following convalescence (3-6 months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate. For certain indications, transesophageal echocardiography (TEE) may be the preferred modality for evaluation. (Please refer to separate TEE policy)

H. Acute Endocarditis

Transesophageal echocardiography (TEE) has a high degree of sensitivity for endocarditis evaluation, and is typically the diagnostic test of choice. TTE can provide diagnostic information; larger vegetations may be directly visualized; and valvular anatomy and ventricular function directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Acutely, examination frequency is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be dictated by the residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves.

I. Pericardial Disease

Detection and quantitation of the amount of pericardial effusion were among the first, and remain important, applications of TTE. Pericardial fluid accumulations as small as twenty (20) milliliters have been reliably diagnosed by TTE. Cardiac motion and blood flow patterns demonstrated by TTE characterize the hemodynamic consequences of pericardial fluid accumulation. A collage of TTE findings has been found to be a reliable indication of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually medically necessary. In a patient with evolving pericardial pathology, a limited focused TTE exam may be appropriate. TTE/Doppler findings have moderate specificity and sensitivity and can be useful in the differential diagnosis of chronic pericardial constriction.

J. Aortic Pathology

TTE can provide valuable information when acute or chronic aortic pathology is present; however, the posterior window of TEE, coupled with the more posterior position of the thoracic aorta, has rendered TEE a more determinative study. Noninvasive TTE remains the study of choice for chronic aortic pathology when images suitable for serial quantitation can be obtained. Frequency of repeat study should be guided by the pathophysiology. In some individuals, such as those with Marfan’s disease or atherosclerotic aneurysms, a focused limited follow-up exam to serially measure aortic diameters and arch diameters may be appropriate.

K. Congenital Heart Disease

In children and small adults TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and noninvasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in selected individuals. When the disease process and therapy are stable, serial assessment by TTE requires medical necessity documentation, if the frequency exceeds an annual evaluation.

L. Suspected Cardiac Thrombi and Embolic Sources

TTE is sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial interstices and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias - especially atrial fibrillation, cardiomyopathies and ventricular dysfunction), TTE usually provides adequate supplemental data for therapeutic decision making. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus and the findings of thrombus or vegetation does not establish a cardiac embolic source. Repeat examinations are not generally medically required in the absence of finding potentially embolic material.

M. Cardiac Tumors and Masses

Infiltrative and ventricular tumors and masses can be visualized, their extent quantitated, and their hemodynamic consequences assessed by TTE. Right atrial space-occupying masses are usually well visualized by TTE. TEE provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, etc.), extensions and attachments. These acute pathologies are not typically followed serially. In specific situations, such as when a tumor is not removed at surgery, and when the patient has had cardiac myxoma removed serial TTEs may be medically necessary to monitor for tumor size or recurrence.

N. Critically Ill and Trauma Patients

There is a role for echocardiography in the management of critically ill patients and trauma victims. The diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion, or a pericardial effusion may be confirmed. Perturbations of volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the clinical situation.

O. Arrhythmias and Palpitations

TTE is useful in defining cardiac function in which Arrhythmias occur, and may be useful in the management of cardiac arrhythmias. Some arrhythmias are frequently associated with underlying organic heart disease or may predispose the patient to hemodynamic deterioration. Atrial fibrillation and atrial flutter are examples of arrhythmias in which echocardiography may be appropriate to assess the underlying disorder. Echocardiographic studies are appropriate only when there is evidence of heart disease. Palpitations without clinical suspicion of arrhythmia, or evidence of heart disease, is not a covered indication for transthoracic echocardiography.

P. Syncope

Determination of the etiology of syncopal episodes can be a difficult clinical problem. The origin may be cardiac, neurological, or due to other causes. Syncope due to cardiac origin is most commonly related to vasodepressor reflexes, bradyarrhythmias, or tachyarrhythmias. Syncope is less commonly caused by cardiac structural disorders. Patients with structurally normal hearts generally have a much more benign prognosis than those with underlying structural coronary artery disease or cardiomyopathic disease. Echocardiography is only appropriate as the initial evaluation, when other findings are suggestive of valvular heart disease or obstructive cardiomyopathy.

Q. Pulmonary

Right heart failure manifesting as edema or ascites may be due to pulmonary hypertension. Pulmonary heart disease may result from acute changes in the pulmonary circulation (e.g., pulmonary embolus) or chronic changes produced by chronic hypoxia that may cause significant right ventricular dysfunction and hypertrophy. Echocardiography may assess right ventricular size and performance, and quantify the severity of pulmonary hypertension using Doppler interrogation of valvular flow signals. Indications include unexplained pulmonary hypertension and pulmonary emboli with suspected clots in the right atrium or ventricle.

R. Follow-up Studies or Limited Studies

A complete study includes a full evaluation of all aspects of the heart, including the cardiac chambers, valves, blood flow, and great vessels. The images are reviewed, measured, analyzed and interpreted by the physician. A report is prepared for the patient’s record. When a less than complete examination is performed for the purpose of evaluation of one specific cardiac problem, or region of the heart, the service is described by CPT codes 93308 and 93321, follow-up or limited studies. When a limited service is performed, or the patient’s condition requires only a limited examination, these codes must be used to indicate the appropriate service.

Examples of appropriate use of CPT code 93308: a follow-up study of a patient with pericardial effusion following heart surgery, to evaluate progression or resolution of the effusion, or a serial evaluation of left ventricular function during antineoplastic chemotherapy.

Examples of appropriate use of CPT Code 93321: recording tricuspid regurgitant velocity in order to estimate pulmonary artery systolic pressure; or sequential evaluation of the transmitral velocity profile in a patient with mitral stenosis, in order to evaluate for a change in gradient or valve area.

S. Doppler Color Flow Velocity Mapping (CPT code 93325)

Doppler color flow-velocity mapping is an appropriate addition to an echocardiogram when the examination is expected to contribute significant information relative to the patient’s condition or treatment plan. Typically, color flow-velocity mapping is indicated in the evaluation of the symptoms of syncope and dyspnea, some heart murmurs, valvular problems, suspected congenital heart disease, complications of myocardial infarction, or cardiomyopathy. Medicare does not cover this service when performed routinely with all echocardiographic exams (i.e., without a clinical indication). This is true even when the results of the test reveal abnormalities. If an unsuspected finding on TTE indicates medical necessity for additional study with Doppler color flow velocity mapping, it can be covered. When the test is performed without a specific indication, it is considered routine screening, and must be billed with a screening ICD-10 code to indicate the reason for the test.

T. Stress Echocardiography (CPT codes 93350, 93351, 93352)

Stress Echocardiography may be necessary when the evaluation could contribute significant information to the patient’s condition or treatment plan. Typically, one stress imaging study (stress echocardiography or nuclear imaging) is adequate to accomplish the assessment. When two (or more) imaging studies are routinely billed (i.e., without a supporting clinical indication), only one of the services will be allowed and the other(s) will be denied as not medically necessary. Pharmacologically induced stress testing is also subject to medical necessity. 

Indications and limitations for stress echocardiography:

1. Acute Myocardial Infarction

Stress echocardiography is not typically performed during the acute phase of a MI when a diagnosis has been established by other methods. In selected patients, stress echocardiography may be necessary when the evaluation could contribute significant information to the patient’s condition or treatment plan.

2. Unstable Angina

Stress echocardiography may be useful as an adjunct to other tests in the diagnosis or treatment of unstable angina only when the combination of history and other tests are not diagnostic. In selected patients, stress echocardiography may be necessary when the evaluation could contribute significant information (e.g. assessment of LV function) to the patient’s condition or treatment plan.

3. Chronic Ischemic Heart Disease

Stress echocardiography may be useful as an adjunct to other tests in the diagnosis or treatment of chronic ischemic heart disease only when the combination of history and other tests are not contributory. In selected patients (e.g. assessment of post-CABG symptoms for ischemia, follow-up of patients with symptomatic ischemic heart disease, or asymptomatic patients requiring follow-up that is customized to their condition and disease process) stress echocardiography may be necessary when the evaluation is expected to contribute significant additional information relating to the patient’s condition or treatment plan.

4. Dilated Cardiomyopathies or Hypertrophic Cardiomyopathy

Stress echocardiography may be useful in the evaluation of cardiomyopathy when the evaluation could reasonably be expected to contribute significant information to the patient’s condition or treatment plan.

5. Post-Transplant Cardiac Disease

Stress echocardiography may be useful in the evaluation of ventricular dysfunction with post-transplant rejection when the evaluation could reasonably be expected to contribute significant information to the patient’s condition or treatment plan.



U. Physician Supervision Requirements

The technical component of TTE must be done under the general supervision of a qualified physician, appropriately trained and skilled in the performance and interpretation of echocardiography. Stress echocardiography is Medicare-covered only when performed under the direct supervision of a qualified physician who provides:
Medical expertise required for the performance of the test;

Medical treatment for complications and side effects of the test;

Medical services required as part of the test, for example, injections or the administration of medications;

Medical expertise in the interpretation of the test, some of which has to be provided during the test and before the patient is discharged from the testing suite.


Billing for Cardiac Echocardiography Services


Cardiac Echocardiography Without Contrast


Hospitals are instructed to bill for echocardiograms without contrast in accordance with the Procedure  code descriptors and guidelines associated with the applicable Level I Procedure  code(s) (93303-93350).

Cardiac Echocardiography With Contrast

Hospitals are instructed to bill for echocardiograms with contrast using the applicable HCPCS code(s) included in Table 200.7.2 below. Hospitals should also report the appropriate units of the HCPCS codes for the contrast agents used in the performance of the echocardiograms.

HCPCS Codes For Echocardiograms With Contrast

HCPCS            Long Descriptor

C8921

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete

C8922

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study

C8923

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography

C8924

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study


C8925

Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report

C8926

Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report

C8927

Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis

C8928

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, 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

C8929

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography

C8930

Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, 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; including performance of continuous electrocardiographic monitoring, with physician supervision

ICD-10 Codes that Support Medical Necessity
  
For Procedure codes 93306, 93307, 93308 (with or without Doppler), C8923 and C8924
   
For Procedure codes 93306, 93307 and 93308 (with or without Doppler)



    A18.84 Tuberculosis of heart

    A40.0 Sepsis due to streptococcus, group A

    A40.1 Sepsis due to streptococcus, group B

    A40.3 Sepsis due to Streptococcus pneumoniae

    A40.8 Other streptococcal sepsis

    A40.9 Streptococcal sepsis, unspecified

    A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus

    A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus

    A41.1 Sepsis due to other specified staphylococcus

    A41.2 Sepsis due to unspecified staphylococcus

    A41.3 Sepsis due to Hemophilus influenzae

    A41.4 Sepsis due to anaerobes

    A41.50 Gram-negative sepsis, unspecified

    A41.51 Sepsis due to Escherichia coli [E. coli]

    A41.52 Sepsis due to Pseudomonas

    A41.53 Sepsis due to Serratia

    A41.59 Other Gram-negative sepsis

    A41.81 Sepsis due to Enterococcus

    A41.89 Other specified sepsis

    A41.9 Sepsis, unspecified organism

    A42.7 Actinomycoti

Many more

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