Medicare Coverage of Echocardiography
Transthoracic Echocardiography (TTE), Current Procedural Terminology (CPT) code 93306, is a noninvasive study that uses ultrasound to visualize the heart’s function, blood flow, valves, and chambers.
This two-dimensional echocardiography, also referred to as real-time imaging, is performed using multiple transducers or a rotating transducer, and these images are recorded on videotape. Computer reconstruction provides the two-dimensional image of specific planes of the heart. M-mode, when performed, provides additional detail of specific portions of the heart. A stationary ultrasound beam is directed at the area of the heart requiring additional study. CPT code 93306 is reported for a complete evaluation that includes spectral and color flow Doppler, which provide information regarding intra-cardiac blood flow and hemodynamics.
Palmetto GBA identified CPT 93306 as an area of vulnerability. This code is a major risk with total potential dollars at risk for this service at $92,215,176, which is an increase of 2.5 percent from the previous year. The Comprehensive Error Rate Testing Contractor (CERT) listed this code in the Top 20 service types with highest improper payments at 100 percent errors for insufficient documentation. It is also one of the services being reviewed by the CERT contractor during 2018 because of its high utilization.
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 (MI)
- Determine the success of reperfusion interventions
- Assess myocardial viability
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. Screening-type evaluations are 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 such 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 diagnostic 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 in the medical record to meet medical necessity. Diagnostic injection services are an integral part of a contrast procedure and are not separately payable.
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 and
- 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
The multifaceted structural and functional information provided by transthoracic echocardiogram (TTE) is unique among diagnostic testing modalities. The rapid and noninvasive acquisition of this information has contributed to exponential application, and potential overutilization. Palmetto GBA’s Local Coverage Determination, L37379 - Echocardiography, addresses the medically necessary and appropriate application of TTE.