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UVMFLOWNET  January 2009

UVMFLOWNET January 2009

Subject:

Re: ICAEL vs ICAVL

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Date:

Thu, 22 Jan 2009 19:50:19 -0500

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2009 - 'you can fool some people all the time and all the people some of the time 
but you cannot fool all the people all the time' (anon?) ... 'No lie lives 
forever' (I've seen MLK & Nietzsche cited as sources) ... the following is a 
modification 

Echocardiography (93303-93352) 

Echocardiography includes obtaining ultrasonic signals from the heart and great 
vessels, with real time image and/or Doppler ultrasonic signal documentation, with 
interpretation and report. When interpretation is performed separately, use 
modifier 26. 

A complete transthoracic echocardiogram without spectral or color flow Doppler 
(93307) is a comprehensive procedure that includes 2-dimensional and selected M-
mode examination of the left and right atria, left and right ventricles, the 
aortic, mitral, and tricuspid valves, the pericardium, and adjacent portions of 
the aorta. Multiple views are required to obtain a complete functional and 
anatomic evaluation, and appropriate measurements are obtained and recorded. 
Despite significant effort, identification and measurement of some structures may 
not always be possible. In such instances, the reason that an element could not be 
visualized must be documented. Additional structures that may be visualized (eg, 
pulmonary veins, pulmonary artery, pulmonic valve, inferior vena cava) would be 
included as part of the service. 

A complete transthoracic echocardiogram with spectral and color flow Doppler 
(93306) is a comprehensive procedure that includes spectral Doppler and color flow 
Doppler in addition to the 2-dimensional and selected M-mode examinations. 
Spectral Doppler (93320, 93321) and color flow Doppler (93325) provide information 
regarding intracardiac blood flow and hemodynamics. 

A follow-up or limited echocardiographic study (93308) is an examination that does 
not evaluate or document the attempt to evaluate all the structures that comprise 
the complete echocardiographic exam. This is typically limited to, or performed in 
follow-up of a focused clinical concern. 

In stress echocardiography, echocardiographic images are recorded from multiple 
cardiac windows before, after, and in some protocols, during stress. The stress is 
achieved by (1) walking on a treadmill; (2) using a bicycle (supine or upright); 
or (3) the administration of pharmacological agents that either simulate exercise 
(by increasing heart rate, blood pressure, or myocardial contractility) or alter 
coronary flow (vasodilation). The patient's ECG, heart rate, and blood pressure 
are monitored at baseline, throughout the procedure and during recovery. Reports 
are prepared to evaluate (1) the duration of stress, the reason for stopping, and 
the hemodynamic response to stress; (2) the electrocardiographic response to 
stress; and (3) the echocardiographic response to stress. 

When a stress echocardiogram is performed with a complete cardiovascular stress 
test (continuous electrocardiographic monitoring, physician supervision, 
interpretation and report), use 93351. Code 93350 is used to report the 
performance and interpretation of a stress echocardiogram only, with the 
components of the cardiovascular stress test reported separately using the 
appropriate codes (93016-93018). 

When left ventricular endocardial borders cannot be adequately identified by 
standard echocardiographic imaging, echocardiographic contrast may be infused 
intravenously both at rest and with stress to achieve that purpose. Code 93352 is 
used to report the administration of echocardiographic contrast agent in 
conjunction with the stress echocardiography codes (93350 or 93351). Supply of 
contrast agent and/or drugs used for pharmacological stress are reported 
separately in addition to the procedure code. 

Report of an echocardiographic study, whether complete or limited, includes an 
interpretation of all obtained information, documentation of all clinically 
relevant findings including quantitative measurements obtained, plus a description 
of any recognized abnormalities. Pertinent images, videotape, and/or digital data 
are archived for permanent storage and are available for subsequent review. Use of 
echocardiography not meeting these criteria is not separately reportable.

Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, 
image documentation and final, written report, is not separately reportable.

(For fetal echocardiography, see 76825-76828)

93303Transthoracic echocardiography for congenital cardiac anomalies; complete 

93304Transthoracic echocardiography for congenital cardiac anomalies;follow-up or 
limited study 

93306Echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography 

(For transthoracic echocardiography without spectral and color Doppler, use 93307) 

93307Echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, complete, without spectral or color 
Doppler echocardiography 

(Do not report 93307 in conjunction with 93320, 93321, 93325) 

93308Echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, follow-up or limited study 

93312Echocardiography, transesophageal, real time with image documentation (2D) 
(with or without M-mode recording); including probe placement, image acquisition, 
interpretation and report 

93313Echocardiography, transesophageal, real time with image documentation (2D) 
(with or without M-mode recording);placement of transesophageal probe only 

93314Echocardiography, transesophageal, real time with image documentation (2D) 
(with or without M-mode recording);image acquisition, interpretation and report 
only 

93315Transesophageal echocardiography for congenital cardiac anomalies; including 
probe placement, image acquisition, interpretation and report 

93316Transesophageal echocardiography for congenital cardiac anomalies;placement 
of transesophageal probe only 

93317Transesophageal echocardiography for congenital cardiac anomalies;image 
acquisition, interpretation and report only 

93318Echocardiography, transesophageal (TEE) 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 

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

(Use 93320 in conjunction with 93303, 93304, 93312, 93314, 93315, 93317, 93350, 
93351) 

93321Doppler 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) 

(Use 93321 in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317, 
93350, 93351) 

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

(Use 93325 in conjunction with 76825, 76826, 76827, 76828, 93303, 93304, 93308, 
93312, 93314, 93315, 93317, 93350, 93351) 

93350Echocardiography, 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; 

 (The appropriate stress testing code from the 93015-93018 series should be 
reported in addition to 93350 to capture the exercise stress portion of the study)

93351Echocardiography, 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 physician supervision 

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

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

(Do not report 93352 more than once per stress echocardiogram) 

(Use 93352 in conjunction with 93350, 93351) 

Franklin W. West
Director, Professional Services
Pacific Vascular Inc.
425.398.7774 (voice)
425.486.8976 (fax)
www.pacificvascular.com
www.PVICME.com 
_______________________________________________
From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Bonnie Johnson
Sent: Thursday, January 22, 2009 3:03 PM
To: [log in to unmask]
Subject: Re: ICAEL vs ICAVL

Is that a regional or a national change?  

Bonnie Johnson RDMS, RVT, FSVU
Vascular Laboratory Manager
Heart & Vascular Institute
El Camino Hospital, Mt. View, CA 

From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Pizzo, Barbara
Sent: Thursday, January 22, 2009 2:55 PM
To: [log in to unmask]
Subject: Re: ICAEL vs ICAVL 

You go girl! Everything you said is very very right. We do so much unpaid work and 
add that to patients that don't pay and no wonder healthcare is in the shape it 
is! If it makes you feel any better, CMS just bundled the codes for Doppler, Color 
and Echo into one. I doubt we will get to unbundle, Cardiology will be bundled 
instead. 

Barbara Pizzo, BS RVT
Technical Director, Vascular, Neurologic and Non-Invasive Cardiology Services
St. Joseph Medical Center
610 378-2802

[log in to unmask]
--------------------------------------------------------------------------------

From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Bonnie Johnson
Sent: Thursday, January 22, 2009 12:47 PM
To: [log in to unmask]
Subject: Re: ICAEL vs ICAVL

This needs to be addressed in ICAVL and on capitol hill.  There are TWO huge 
issues involving TIME and REIMBURSEMENT.  We do not get to differentiate between 
upper and lower extremity vein studies (they are one CPT)  yet we still have to do 
them when they are ordered. It does happen in patients who have had multiple 
lines, fistulas or coagulopathy.  The same applies when we do preop evaluations 
for fistulas and have to map the arm veins bilaterally and assess the arterial 
side – also only paid for ONE as vein and artery are rarely allowed on the same 
day/same patient.  Add to this issue the time it takes to perform these types of 
tests (not to mention preop venous reflux studies).   

Time definitely needs to be allowed for and the reimbursement disparities need 
addressed.  ECHO continues to unbundle and get paid for multiple CPT’s per case 
while vascular is not only bundled but the bundled codes are bundled!!!  It takes 
longer to perform these types of exams and we get paid less.  Many radiology based 
ultrasound labs call themselves a vascular lab and cranks out 15 minutes worth of 
photos and our reimbursements are linked to that rather than reality.  THIS NEEDS 
FIXED. We need a new tiered system like OB ultrasound…….level 1 and level 2 
vascular studies.  Where one level is more basic and shorter in duration and the 
other level is advanced and longer (ie REAL vascular lab).  The reimbursements 
should be linked to the amount of work & level of clinical skills involved in 
performing the procedure.   Perhaps we could start with all PREOP studies being 
considered a higher level requiring more time and more reimbursement.  I guess 
that brings in new CPT codes and the RUC committee etc etc. …. But hey, that did 
not stop the cardiologists.   bj 

Bonnie Johnson RDMS, RVT, FSVU
Vascular Laboratory Manager
Heart & Vascular Institute
El Camino Hospital, Mt. View, CA

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