Transesophageal Echocardiography (TEE) CPT code 93312 - 93318

Echocardiography is a non-invasive technique in which pulsed high-frequency sound waves are used to visualize the contours, movements and dimensions of cardiac structures. Ultrahigh frequency sound waves are directed toward and reflected by cardiovascular structures. Reflected echoes are translated into electrical impulses for display on a monitor and for recording and storage on either videotape or digital recording.

Echocardiography (or cardiac ultrasound) provides structural, functional and hemodynamic information. It can also provide anatomic information pertaining to the proximal great vessels. An ultrasound generator is a non-invasive diagnostic tool, which can be applied to the anterior thorax to examine the heart. This exam is known as Transthoracic Echocardiography (TTE). (For coverage of TTE, refer to the “Transthoracic Echocardiography (TTE) – 4C-52” LCD.) The ultrasound generator can also be positioned in the esophagus to obtain additional cardiovascular information. This exam is known as Transesophageal Echocardiography (TEE). Because of the esophageal instrumentation, TEE is relatively invasive with potential for morbidity.

TEE is not usually medically necessary when a technically adequate normal TTE has been performed. If TTE is technically inadequate or demonstrates pathology but does not provide adequate data for definitive therapeutic decision, TEE is appropriately considered. The information TEE is expected to provide should significantly augment that obtained by TTE and contribute to clinically relevant management decisions (alter therapy).

Significant esophageal pathology (tumor, stenosis, varices, diverticula) is considered as relatively contraindicatingTEE. The anticipated incremental information obtained clearly should exceed any potential risk.

This policy defines clinical pathophysiologic states for which TrailBlazer will provide coverage for TEE examinations. Covered conditions reflect those for which there is authoritative literature support as to clinical utility.

Indications

Native Valvular Heart Disease: Native valvular heart disease in the absence of proven or suspected endocarditis is appropriately assessed by TTE. It is seldom medically necessary to complement TTE with TEE. TTE provides non-invasive assessment of native valve functional anatomy and ventricular adaptation and function. When TTE is technically inadequate, TEE may provide comparable data. Serial assessment by relatively invasive TEE is not as ideal as serial assessment by non-invasive TTE.

Endocarditis: When TTE provides diagnostic information pertaining to valvular pathology, the infective process and ventricular function, TEE is not generally necessary. TTE affords non-invasive serial assessment and is generally better able to define the consequences of the infective valvular process on ventricular function. When TTE has provided diagnostic formation, the supplemental information provided by TEE should generally have therapeutic relevance. When the suspicion of endocarditis is high (persistent febrile state, negative cultures, preexistent valvular pathology) and TTE does not document endocarditis, TEE may define small vegetative masses and more completely delineate local complications (e.g., ring abscesses, aneurysm, fistulae).

Valvular Prostheses (Mechanical and Bioprostheses): In most patients with valvular prostheses, TTE provides diagnostic functional information and non-invasive serial follow-up. However, in some patients, the prosthetic valve may cause acoustical shadowing that may diminish the value of the TTE. When prosthetic dysfunction is suspect and therapeutic decisions are pivotal and data inconclusive, TEE is appropriately considered. TEE is not routinely indicated in all patients with prosthetic valves.

Suspected Cardiac Thrombi and Emboli: Historical estimates place the incidence of a cardiac source of emboli at between 15 and 30 percent. Selective study of these patient cohorts by TTE detects a potential cardiac source in 10 percent. In general, TTE can reliably diagnose or exclude a ventricular locus of potentially embolic material. In patients with cardiac pathology associated with a high incidence of thromboembolic (valvular heart disease, arrhythmias – especially atrial fibrillation, cardiomyopathies, other causes of ventricular dysfunction) the incremental information provided by TEE should be of therapeutic relevance before the patient is subjected to TEE. Routine TEEto search for a cardiac source of embolization is not considered necessary. In younger stroke patients with a normalTTE and neurologic workup, TEE is appropriately considered. A key decisional factor should be whether TEE findings may substantively alter therapy and clinical outcome. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus, and the finding of thrombus or vegetation does not establish a cardiac embolic source.

Aortic Pathology: TEE has become an established rapid and reliable tool for the diagnosis and definition of aortic dissection and aneurysm. Sensitivity and specificity in the range of 97 percent is consistently reported. In suspected aortic dissection, the application of bedside biplane or multiplane TEE is frequently considered the diagnostic study of choice.

Aortic ulceration, atherosclerotic plaque and mural thrombotic material are identified by TEE with increasing frequency particularly in older patients. A causative relationship between these findings and embolic events is postulated. At present, TEE investigation for this pathology can not be considered routine. If embolic episodes are repetitive and focused aortic surgical intervention is contemplated, TEE to search for and characterize remediable aortic lesions may be appropriate.

Congenital Heart Disease: In children and smaller adults TTE provides accurate anatomic definition of congenital heart diseases. In larger and postoperative patients with fibrosis, echo opaque patches and prostheses, inadequate penetration and acoustical shadowing can result in incomplete TTE data. The more precise definition of atrial, outflow tract and proximal pulmonary vascular anomalies by TEE can be critical to management strategies. When TTE is technically inadequate or anatomic definition incomplete, TEE is appropriately considered.

Interventional and Surgical TEE: TEE can be of utility during percutaneous and surgical cardiac interventions. In selected instances, TEE can provide guidance during the creation of shunts, placement of septation devices, performance of valvular plastic procedures and replacement when the surgical result cannot be adequately assessed by other means. In lung or heart-lung transplant, the integrity and morphology of pulmonary vascular anastomoses is critical. Intraoperative TEE can assist in surgical management decisions.

Intraoperative TEE monitoring of ventricular function in selected high-risk patients can complement hemodynamic monitoring data. Assessment for changes in volume and of global and regional myocardial contractility can be therapeutically useful. Routine application, even in patients undergoing cardiopulmonary bypass and valvular surgeries, cannot be supported. Prior to elective percutaneous mitral valvuloplasty, TEE is used to assess for left atrial thrombi.

Medicare payment for the professional component of intraoperative TEE is justified for instances in which intraoperative echocardiography is an adjunct to optimal performance of a surgical procedure or for a specific diagnostic reason (e.g., proper valve placement, guiding of the placement of a device to close an atrial septal defect, evaluation of mitral balloon valvuloplasty, etc.). Intraoperative echocardiographic services must include a complete interpretation and written report by the performing physician, and images obtained must be stored in the same manner as other echocardiographic services to warrant separate payment.

For services on or after May 22, 2007, CMS national policy permits Medicare coverage for monitoring cardiac output by transesophageal Doppler for ventilated patients in the ICU and operative patients with a need for intraoperative fluid optimization.

See associated article for coding instructions regarding transesophageal Doppler cardiac output measurement performed for intraoperative and ventilated patient ICU hemodynamic monitoring.

Critically Ill ICU Patients: There is a role for echocardiography in the management of the critically ill patient. WhenTTE fails to provide adequate visualization (Chronic Obstructive Pulmonary Disease (COPD), ventilator patient), TEEmay provide diagnostic information and help guide therapy. A persistent unexplained fever, a reasonable probability of remediable aortic, cardiac or central pulmonary vascular pathology, or inadequately defined volume status are among the accepted indications.

Cardiac Tumor and Mass Assessment: TEE and TTE have comparable sensitivity in the assessment of right-heart masses. TEE provides more detail of left atrial masses and may provide therapeutic direction (cystic versus solid, attachment, infiltration). When cardiac mass lesions are suspect, TEE can be an integral part of the diagnostic workup and management strategy.

Cardioversion: Prior to cardioversion of atrial fibrillation when anticoagulants are contraindicated or of unusually high risk, information obtained by TEE may facilitate therapeutic decisions. When anticoagulants are considered integral to the cardioversion and there is no contraindication to their use, incremental therapeutic information provided by TEEhas not been demonstrated. TEE may define small vegetative masses and more completely delineate local complications (e.g., ring abscesses, aneurysm, fistulae).

Pericardial Disease: TEE has not been demonstrated to provide incremental information to that provided by TTE in the assessment and management of pericardial pathology.

Left Ventricular Function: In general, TTE provides accurate and serial non-invasive assessment of global and regional left ventricular function. When TTE is technically inadequate and clinical data insufficient for management decision, TEE can provide comparable information. TTE assessment of left ventricular function is considered preferable to TEE in all other circumstances.

Limitations:

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

0480, 0483

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
93312©	Echo transesophageal
93313©	Echo transesophageal
93314©	Echo transesophageal
93315©	Echo transesophageal
93316©	Echo transesophageal
93317©	Echo transesophageal
93318©	Echo transesophageal intraop

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 93312, 93313, 93314, 93315, 93316, 93317 and 93318:

Covered for:

038.0	Streptococcal septicemia
038.10–038.11	Staphylococcal septicemia
038.19	Other staphylococcal septicemia
038.2–038.3	Septicemia
038.40–038.44	Septicemia due to other gram-negative organisms
038.49	Other septicemia due to gram-negative organisms
038.8–038.9	Septicemias
164.1	Malignant neoplasm of heart
198.89	Secondary malignant neoplasm of other specified sites
212.7	Benign neoplasm of heart
238.8–238.9	Neoplasm of uncertain behavior of other and unspecified sites and tissues
239.89	Neoplasm of unspecified nature of other specified sites
276.50–276.52	Volume depletion
276.6	Fluid overload
362.30–362.37	Retinal vascular occlusion
368.00–368.03	Amblyopia ex anopsia
368.10–368.16	Subjective visual disturbances
391.0–391.2	Rheumatic fever with heart involvement
394.0–394.2	Diseases of mitral valve
395.0–395.2	Diseases of aortic valve
395.9	Other and unspecified rheumatic aortic diseases
396.0–396.3	Diseases of mitral and aortic valves
396.8–396.9	Diseases of mitral and aortic valves
397.0–397.1	Diseases of other endocardial structures
410.00–410.02	Acute myocardial infarction of anterolateral wall
410.10–410.12	Acute myocardial infarction of other anterior wall
410.20–410.22	Acute myocardial infarction of inferolateral wall
410.30–410.32	Acute myocardial infarction of inferoposterior wall
410.40–410.42	Acute myocardial infarction of other inferior wall
410.50–410.52	Acute myocardial infarction of other lateral wall
410.60–410.62	True posterior wall infarction
410.70–410.72	Subendocardial infarction
410.80–410.82	Acute myocardial infarction of other specified sites
410.90–410.92	Acute myocardial infarction of unspecified site
414.00–414.05	Coronary atherosclerosis
414.10–414.11	Aneurysm and dissection of heart
414.19	Other aneurysm of heart
414.2–414.3	Other forms of chronic ischemic heart disease
415.0	Acute cor pulmonale
415.11–415.12	Pulmonary embolism and infarction
415.19	Other pulmonary embolism and infarction
417.0–417.1	Other diseases of pulmonary circulation
421.0–421.1	Acute and subacute bacterial endocarditis
422.91–422.93	Other and unspecified acute myocarditis
423.3	Cardiac tamponade
424.0–424.3	Other diseases of endocardium
424.90–424.91	Endocarditis valve unspecified
425.1	Hypertrophic obstructive cardiomyopathy
427.31–427.32	Atrial fibrillation and flutter
429.4–429.6	Ill-defined descriptions and complications of heart disease
429.71	Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
429.81	Other disorders of papillary muscle
429.83	Takotsubo syndrome
433.00–433.01	Occlusion and stenosis of basilar artery
433.10–433.11	Occlusion and stenosis of carotid artery
433.20–433.21	Occlusion and stenosis of vertebral artery
433.30–433.31	Occlusion and stenosis of multiple and bilateral precerebral arteries
433.80–433.81	Occlusion and stenosis of other specified precerebral artery
434.10–434.11	Cerebral embolism
434.90–434.91	Cerebral artery occlusion unspecified
435.0–435.3	Transient cerebral ischemia
435.8–435.9	Transient cerebral ischemias
436	Acute but ill-defined cerebrovascular disease
440.0	Atherosclerosis of aorta
441.01	Dissection of aorta thoracic
441.03	Dissection of aorta thoracoabdominal
441.1–441.2	Aortic aneurysm and dissection
441.6–441.7	Aortic aneurysm and dissection
444.0–444.1	Arterial embolism and thrombosis
444.21–444.22	Arterial embolism and thrombosis of the extremities
444.81	Embolism and thrombosis of iliac artery
444.89	Embolism and thrombosis of other artery
453.2–453.3	Other venous embolism and thrombosis
458.9	Hypotension unspecified
459.2	Compression of vein
557.0	Acute vascular insufficiency of intestine
593.81	Vascular disorders of kidney
745.0	Common truncus
745.10–745.12	Transposition of great vessels
745.19	Other transposition of great vessels
745.2–745.5	Bulbus cordis anomalies and anomalies of cardiac septal closure
745.60–745.61	Endocardial cushion defects
745.69	Other endocardial cushion defects
745.7	Cor biloculare
746.00–746.02	Anomalies of pulmonary valve
746.09	Other congenital anomalies of pulmonary valve
746.1–746.7	Other congenital anomalies of heart
746.81–746.85	Other specified anomalies of heart
747.0	Patent ductus arteriosus
747.10–747.11	Coarctation of aorta
747.21–747.22	Congenital anomalies of aorta
747.29	Other congenital anomalies of aorta
747.3	Congenital anomalies of pulmonary artery
747.40–747.42	Anomalies of great veins
780.02	Transient alteration of awareness
780.60–780.62	Fever
785.50–785.51	Shock without mention of trauma
785.59	Other shock without trauma
786.05	Shortness of breath
786.09	Respiratory abnormality other
786.51	Precordial pain
958.4	Traumatic shock
996.01–996.02	Mechanical complication of cardiac device, implant and graft
996.61	Infection and inflammatory reaction due to cardiac device implant and graft
996.71	Other complications due to heart valve prosthesis
996.72	Other complications due to other cardiac device implant and graft
998.0	Postoperative shock not elsewhere classified
998.51	Infected postoperative seroma
998.59	Other postoperative infection
999.1	Air embolism as a complication of medical care not elsewhere classified
999.31	Infection due to central venous catheter
V12.53	Personal history of sudden cardiac arrest
V15.1	Personal history of surgery to heart and great vessels presenting hazards to health
V42.1	Heart replaced by transplant
V42.2	Heart valve replaced by transplant
V42.6	Lung replaced by transplant
V43.3	Heart valve replaced by other means

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
• At a minimum, a complete study should include (2-D with or without M-mode) measurements of left ventricular end diastolic diameter, left ventricular end systolic diameter, left ventricular wall thickness, left atrial diameter, aortic valve excursion, qualitative description of left ventricular function and, as applies, a description of any technical limitations for particular cases. Valid substitutes for the previous parameters may be recorded, such as LV volumes, ejection fraction and LV mass measurements.
• The rationale for performing the study(s) must be clearly documented in or understood from the medical record.
• Medical records, including the permanent image, need not be submitted with the claim. However, these records must be furnished to Medicare upon request.
• The ordering physician must furnish to the performing provider the appropriate diagnostic material needed for billing the TEE.

Appendices

N/A

Utilization Guidelines

Medical necessity of repeated echocardiographic studies varies widely. Certain patients require only one study to establish a diagnosis and/or establish a baseline function. The frequency of serial examination should be dictated by the individual patient’s clinical course.

Notice: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.