Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27535

Transesophageal Echocardiography (TEE)

L27535

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Manual System, IOM Pub. 100-03, Medicare National Coverage Determinations (NCDs) Manual, Section 220.5.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

NOTE: This LCD applies only to the diagnostic imaging uses of Transesophageal Echocardiography (TEE), not to the monitoring of cardiac output. For information about the monitoring of cardiac output, please see CMS NCD 220.5.

Cardiac ultrasound provides structural, functional and hemodynamic information. It can also provide anatomic information pertaining to the proximal great vessels (major arteries and vessels near the heart). The basic transesophageal echocardiography (TEE) equipment is a two-dimensional doppler color flow imaging system to which a transesophageal echocardiogram transducer can be attached. The TEE transducer is a modification of a conventional endoscope. This bi-plane or multi-plane transducer is capable of high resolution imaging, colorflow, pulsewave, and continuous wave doppler. The instrument is placed in a manner similar to the placement of the flexible endoscopic gastroscope.

TEE is not usually medically necessary when a technically adequate normal transthoracic echocardiography (TTE) has been performed. If TTE is technically inadequate, provides incomplete information, 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, history of dysphagia, recent esophageal operation, upper GI bleed) may be considered contraindications. The anticipated benefits must clearly exceed any potential risk.

Coverage for TEE is allowed and indicated in the following situations: When TTE has not established the diagnosis, or in a patient where TTE is felt not to give adequate information (e.g., as in extreme obesity, severe COPD, chest deformity, inadequate or incomplete visualization of the left atrium and left atrial appendage in patients with prosthetic material, and inadequate visualization of the atrial septum for making the diagnosis of patent foramen ovale).

A TEE may be performed as an initial test in the following scenarios: There is suspected acute aortic pathology including dissection or transection; for guidance of percutaneous non coronary cardiac interventions (e.g., radiofrequency ablation of atrial arrhythmias, alcohol septal ablation, percutaneous mitral valvuloplasty, atrial occluder device deployment); to determine the mechanism of valve regurgitation and/or suitability for valve repair; to diagnose or subsequently manage suspected endocarditis with moderate or high pre-test probability of the disease; persistent fever with an intracardiac device; or for clinical decision making, including possible cardioversion or radiofrequency ablation of atrial flutter or atrial fibrillation when anticoagulation alone is not already planned.

A. Native and Prosthetic Valvular Heart Disease

Native valvular heart disease in the absence of proven or suspected endocarditis may be appropriately assessed by TTE. It is rarely medically necessary to complement TTE with TEE. TTE provides a noninvasive assessment of native valve functional anatomy and ventricular adaptation and function. When TTE is technically inadequate, a TEE may provide additional useful clinical information. Serial assessment by relatively invasive TEE is not as ideal as serial assessment by a noninvasive TTE. Prior to possible valve surgical repair, TEE is useful to further assess the mechanism and severity of disease and the extent of surgery required. Prior to elective percutaneous balloon mitral valvuloplasty a TEE is needed to exclude the presence of left atrial thrombus and it may be useful as a guide to the procedure.

In most patients with valvular prostheses TTE provides diagnostic functional information and a noninvasive serial follow-up. TEE is appropriately considered when TTE results are inconclusive, and/or the left atrium must be visualized (the left atrium is not visible with TTE). TEE is not routinely indicated in all patients with prosthetic valves.

B. Bacterial Endocarditis

When endocarditis is established or the suspicion of endocarditis is high (persistent febrile state, negative cultures, pre-existent valvular pathology), TEE is considered the standard of care. Bacterial endocarditis is a rare diagnosis that carries a high mortality rate (10-20%). TEE may define small vegetative masses and more completely evaluate local complications (e.g., ring abscesses, aneurysm, fistulae).

C. Source of Embolism

In general, TTE can reliably diagnose or exclude evidence of potentially embolic material located in a ventricle. In patients with cardiac pathology associated with a high incidence of thromboembolism (valvular heart disease, arrhythmias - especially atrial fibrillation, cardiomyopathies, other causes of ventricular dysfunction), the additional information provided by TEE should be of therapeutic relevance before the patient is subjected to TEE. Transesophageal echocardiogram to search for a cardiac source of embolization is appropriate for certain patients with a negative transthoracic echocardiogram. In addition, proceeding directly to TEE may be justified in certain patient populations. In such cases the medical record should indicate the reason for proceeding directly to a TEE.

D. Cardiac and Pericardiac Masses

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

E. Aortic Pathological Conditions

TEE has become an established rapid and reliable tool for the diagnosis and definition of aortic dissection and aneurysm. 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 patient populations. A causative relationship between these findings and embolic events is being considered. At present, TEE investigation for this pathology cannot 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.

F. Critically Ill Patients

There is a role of echocardiography in the management of the critically ill patient. When TTE fails to provide adequate visualization, or TTE is contraindicated (e.g., chest trauma), TEE may provide diagnostic information and help guide therapy. Examples where TEE may be useful: assessment of complications of myocardial infarction, hypotension, persistent hypoxemia in patients suspected of having a right-to-left shunt, patients in shock, and brain-dead patients being considered as cardiac donors.

G. Congenital Heart Disease

In children and smaller adults TTE provides accurate anatomic definition of congenital heart diseases. In adults and postoperative patients, TEE may be appropriate for complications of congenital heart surgery, visualization of shunt flow across atrial septal defects, guidance of a clam-shell device to close atrial septal defects, diagnosis of cor triatriatum, and detection of pulmonary valve abnormalities. When TTE is technically inadequate or anatomic definition is incomplete TEE may be considered medically necessary.

H. Intraoperative Use

The interpretation of TEE during surgery is covered only when the surgeon or other physician has requested echocardiography for a specific diagnostic reason (e.g., determination of proper valve placement, assessment of the adequacy of valvuloplasty or revascularization, placement of shunts or other devices, assessment of ventricular function, assessment of vascular integrity, or detection of intravascular air). To be a covered service TEE must include a complete interpretation/report by the performing physician. Only one interpretation will be covered per operative session.

I. Cardioversion

TEE is used for the evaluation of patients with atrial fibrillation/flutter to facilitate clinical decision making with regards to anticoagulation and/or cardioversion and/or radiofrequency ablation. However, when anticoagulants are considered integral to the cardioversion and there is no contraindication to their use, incremental therapeutic information provided by routine TEE has not been demonstrated.

Echo contrast agents will be reimbursed for echocardiography enhancement when a conventional study echocardiogram has failed to opacify the left ventricle. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders. This is especially applicable during the performance of exercise echocardiographic stress testing.

The accuracy of cardiac ultrasound depends on the knowledge, skill and experience of the sonographer and physician. Sonographers who perform or supervise the studies must be capable of demonstrating training and experience specific to the study performed and maintain documentation for postpayment audit. Physicians who perform, supervise, and/or interpret the studies must be capable of demonstrating training and experience specific to the study performed or interpreted and maintain documentation for postpayment audit. A physician or a sonographer may personally perform cardiac ultrasound procedures. When a physician employs auxiliary personnel to assist him/her in rendering ultrasound procedures, the services of such personnel are considered "incident to" the physician's service. All guidelines set forth by CMS regarding "incident to" must be met.

Diagnostic Tests and X-Rays, Outpatient Hospital Services

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

Adequate documentation is essential for high quality patient care. There should be a permanent record of the echocardiogram and its interpretation included in the medical record. The interpretation should be a comprehensive report addressing the relevant clinical history and issues, comparative information (when available), and complete interpretive impression/findings. Images of all appropriate areas, both normal and abnormal, should be recorded. Variation from normal size should be accompanied by measurements.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. 

Other Contractor’s Policies (Highmark Medicare Services Pennsylvania Carrier and Highmark Medicare Services Maryland/Washington, D.C. Fiscal Intermediary, Louisiana, Virginia, Wisconsin, New York, Utah)

Model Local Medical Policy 1996

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from Cardiology.

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27535

07/31/2008

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