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Pocket these tips for billing echocardiography services.

Echocardiography (鈥渆cho鈥�) is a procedure that uses high-frequency ultrasound waves to create an image of the heart鈥檚 structures and function. The primary focus of pediatric echocardiography is the detection of congenital heart defects, evaluation of the basis of cardiac arrhythmias (irregular heartbeats), and detection of acquired heart diseases. Echocardiography may also be used for the evaluation of heart murmurs and effectiveness of medical therapy and surgical treatments.

Echocardiography modalities can be separately billed in some circumstances. Keep reading to learn more.

Be Familiar With Echocardiography CPT^庐 Codes 93306-93308

Complete transthoracic echocardiography (TTE) is billed with CPT^庐 code 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), which requires the documentation of all nine required structures (left and right atrium, left and right ventricle; aortic, mitral and tricuspid valves; aorta; and pericardium) with modalities (complete spectral and color Doppler).

There are optional structures that might be documented but are not required, including pulmonary valve, pulmonary vein, pulmonic artery, and inferior vena cava. A bubble study is also sometimes performed to evaluate for a patent foramen ovale (PFO), but it is not billed with a separate code and is always considered included in the echocardiography CPT^庐 code billed.

Here鈥檚 a look at additional transthoracic echocardiography codes:

• CPT^庐 code 93307 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography) includes all nine required structures without spectral and color doppler documented.
• CPT^庐 code 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study) is used when fewer than nine structures are documented.

It is still appropriate to bill the complete TTE when one or more of the structures are not well visualized, as long as the reason for the poor imaging is documented, like 鈥渂ody habitus.鈥�

Top tip: If the report indicates that a limited echo was performed, but there are documented findings for all nine elements, report a complete echo. If the report indicates that a complete echo was performed, but there are findings for fewer than the required nine elements, report a limited study.

Know These Modalities Are Billable With Echocardiography

There are multiple CPT^庐 add-on codes that are allowable when billing echocardiography services, including CPT^庐 codes +93321, +93325, +93356, 76376-76377, and +0439T.

Please keep in mind that code 93306 includes spectral and color Doppler; therefore, they would never be billed separately:

Here鈥檚 a look at the codes you might report along with an echocardiography:

• +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)) is an add-on code for limited spectral doppler and is billable with code 93308.
• +93325 (Doppler echocardiography color flow velocity mapping 鈥�) is also another add-on code for color doppler billable with 93308.
• +93356 (Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics 鈥�) is used when myocardial strain imaging is used and documented appropriately. This must be documented as a modality, as well as findings in the report. Myocardial strain imaging measures the global longitude strain (GLS) in the left ventricle. Findings are often given in a 鈥�%鈥� format but may state 鈥淕LS is abnormal or normal.鈥�
• 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation) is used when 3D imaging does not require image postprocessing on an independent workstation, or it is not documented whether it was on an independent workstation.
• 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation) is used when 3D image does require image postprocessing on an independent workstation.
• Category III code +0439T (Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure)) must be documented as a modality, as well as findings in the report. Documentation must reflect that the physician did an additional myocardial assessment for viability or ischemia above and beyond what is included in an echocardiographic study. Examples of contrast material used includes but is not limited to Definity, Optison or Lumason.

Try These Coding Tips for TTE

Per the Medicare NCCI Policy Manual, when billing an aortic/mitral valve replacement procedure, codes 93306-93308 should not be separately reported by the physician performing the transcatheter aortic/mitral valve replacement procedure. Code 93306 cannot be reported based on whether regurgitation/insufficiency is documented in the findings. Spectral and color Doppler must also be documented as either modalities in the procedure description or in the report findings (e.g., color Doppler demonstrated aortic valve regurgitation).

Also, keep in mind that codes 93306-93308 can be billed as global, professional, or technical components separately with either modifier 26 (Professional component) for the professional component or modifier TC (Technical component) for the technical component.

Top tip: When a bubble study is documented, look for agitated saline to be used and remember that it is not a contrast material 鈥� so don鈥檛 mistake it for Definity, Optison or Lumason. 

Look to Examples for Guidance

To bring all of this coding advice together, check out examples for acceptable documentation of modalities:

• 鈥淟imited spectral Doppler and color flow doppler was performed to determine the moderate tricuspid insufficiency.鈥�
  Coding: Look to codes +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)) to +93325 (Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography).
• 鈥淭he average left ventricular global longitudinal strain is -12.8%. The global longitudinal strain is abnormal.鈥�
  Coding: Look to +93356 (Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (List separately in addition to codes for echocardiography imaging).
• 鈥淟eft Ventricular ejection fraction by 3D volume is 46%.鈥�
  Coding: When documentation doesn鈥檛 specify the independent workstation, code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation).
• 鈥淓jection fraction is 55% and was determined by 3D postprocessing on an independent workstation.鈥�
  Coding: Look to 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation).
• 鈥淓ndocardium was not well visualized; however, appears to be normal regional wall motion with Definity contrast.鈥�
  Coding: Look to +0439T (Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure).

Cristin Robinson, CPC, CPMA, CCC, CRC, Contributing Writer