Stress Echo


• CPT codes: 93350, 93351





CPT CODE 93350  Echo, Stress


Description 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 (Do not report in conjunction with 93015)


Fee amount average $242




• Stress testing codes 93016-93018 should be reported, when appropriate, in conjunction with 93350 to  capture the cardiovascular stress portion of the study



• Do not report 93350 in conjunction with 93015


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. 



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

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. 




CPT CODE 93351  Echo, Stress



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; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional


Prior to 2009 if an individual physician performed all elements of a stress echocardiographic study (i.e., both the stress echo imaging portion and the stress EKG), he/she reported CPT codes 93350 and 93015. Under the new coding structure, a physician who performs all elements required will report CPT code 93351. However, physicians that do not perform all elements will use CPT code 93350 to report the performance and interpretation of the stress echocardiographic imaging study only with the appropriate components of the cardiovascular stress codes reported separately (93016 – 93018). For example, if a physician does not analyze, interpret and report on the cardiovascular stress test, but does supervise the performance of the stress test along with the stress echo, he/she would report 93350 and 93016.




Average fee amount $272


• Do not report 93351 in conjunction with 93015-93018, 93350

• Do not report 93351-26 in conjunction with 93016, 93018, 93350-26


when a stress echocardiography test is performed with continuous lectrocardiographic 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)




Sometimes a physician will order a Stress Echocardiogram to evaluate the motion of the heart’s walls and pumping action when the heart is stressed. This will help him/her to better determine a lack of blood flow that isn’t always apparent on other heart tests. During a stress echo images are recorded before, after and sometimes during stress. Patient’s EKG, heart rate and blood pressure are also monitored before, during and after test. The goal is to evaluate hemodynamic, electrocardiographic and echocardiographic responses to stress.


To report stress echo:


93350 – Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle and/or pharmacologically induced stress with interpretation and report 



+ 93352 Use of contrast agent during stress echocardiography






 In general, stress echo (SE) and nuclear myocardial perfusion imaging (MPI) are considered equivalent diagnostic tests. However, in addition to myocardial ischemia, SE by its nature can provide additional information that is not obtainable with MPI such as valve function, assessment of pulmonary pressure, and assessment of dynamic obstruction and may be preferable if abnormalities in these parameters are known or suspected. 


 Doppler echo with a stress echo may be used for evaluation of the following: 


o Shortness of breath


o Known or suspected valvular disease


o Known or suspected hypertrophic obstructive cardiomyopathy such as idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy



o Assessment of pulmonary pressures 

Q: Also the new code 99351 for a tress echo is paying a lot less than the older three codes we use to bill. Can we use any other code?



Code 93351 is inclusive of stress test and stress echo procedures. Physicians report 93351 when the same physician provides all components (the stress echo and stress test supervision/ interpretation). 93351 is reported by the hospital when both stress echo and stress testing is performed (without contrast). The AHA Coding Clinic has also given guidance that 93351 is the applicable code to report, regardless if the stress test and stress echo is done in different departments. there are no alternative codes that may be reported.


Historically, hospitals have charged 93350 plus 93017 for the stress testing component. Why a hospital reported 93351 instead of 93350 plus 93017? Both of these codes pay the same APC rate. Can you explain how to bill 93351 properly?




First, review the descriptor for 93351 included in your question. CPT 2009 Changes, An Insider’s View states that 93351 “was established to report a stress echocardiogram combined with a complete cardiovascular stress test.”


It further states that:
Previously, code 93350 was a stand-alone code. Code 93350 has been revised to support the establishment of a child (indented) code 93351. Code 93350 is used to report the performance and interpretation of a stress echocardiogram only. Bill codes 93015–93018 if the stress test is performed in a hospital setting, along with procedure code 93350. If the stress test and echocardiogram are performed in an office, bill combined code 93351. 

CPT CODE 93352  Echo contrast agent (SE only) group 93




For the first time, a code will be available to report administration of a contrast agent during stress echocardiography. Using CPT 93352, physicians performing contrast enhanced stress echocardiography (CPT codes 93350 or 93351) are now able to separately report services associated with contrast administration.  The contrast agent is reported with the appropriate Healthcare Common Procedure Coding System (HCPCS) supply code. Total RVUs of 1.07 for CPT 93352 yields a national average Medicare payment of approximately $36.



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. 




• Do not report 93352 more than once per stress echocardiogram



• Use 93352 in conjunction with 93350, 93351




Billing and Coding Guidelines



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.


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


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).


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.


Anthem Central Region bundles 93307 as incidental with 93350, bundles 93307-26 as incidental with 93350-TC and bundles 93307-TC as incidental with 93350-TC. Based on the National Correct Coding Initiative Edits, code 93307 is listed as a component code to code 93350. Therefore, if 93307 is submitted with 93350— only 93350 reimburses, if 93307-26 is submitted with 93350-26—only 83350-26 reimburses and if 93307-TC is submitted with 93350-TC—only 93350-TC reimburses.








Transthoracic Echocardiography (TTE) Policy 


Policy
Transthoracic 


Echocardiography (TTE) is a standard echocardiogram or cardiac ultrasound. A probe is placed on the
patient’s thorax and images of the heart are taken through the chest wall. TTE provides a non-invasive assessment of the
health of the heart.
Harvard Pilgrim reimburses contracted providers for transthoracic echocardiography for covered indications.
Harvard Pilgrim Health Care payment policy is consistent with the Centers for Medicare and Medicaid (CMS) LCD Transthoracic
Echocardiography policy.




Transthoracic Echocardiography (TTE) CPT codes


 CPT Description


93303 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study


93304 Transthoracic echocardiography for congenital cardiac anomalies; complete




Transthoracic Echocardiography 2D (2D TTE) CPT codes


CPT code  Detailed Description


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


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


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


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 pharmacologically induced
stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional




Billing and Coding Information for Echocardiogram CPT CODES


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.