Cardiology relies heavily on non-invasive procedures to diagnose heart function under stress, such as CPT code 93351. Billing for these procedures requires precision and knowledge about industry best practices.
Thus, if you are a cardiologist struggling with a higher denial rate or an unsteady cash flow while billing for a transthoracic echocardiography procedure, this blog is for you!
It discusses everything you need to know about billing CPT 93351. These include details about applicable modifiers, reimbursement guidelines, and clinical scenarios.
So, without further ado, let’s get started!
CPT Code 93351 – Description
CPT code 93351 covers physician-supervised continuous transthoracic echocardiography (stress TTE) at both rest and after exercise. It also involves image review along with assessment of global and ventricular performance and other cardiac causes of chest pain.
Simply put, this code covers supervision, professional (interpretation and reporting), and technical components.
Scenarios Where CPT Code 93351 is Applicable
Let’s review a few real-world clinical scenarios related to stress TTE for better understanding:
Angina Pectoris Evaluation
Picture a 58-year-old female patient with the onset of shortness of breath during moderate activity and angina pectoris (atypical exertional chest pain). The baseline EKG came back normal. However, risk factors include hyperlipidemia and hypertension.
Therefore, the cardiologist orders a transthoracic stress echocardiogram to determine if the symptoms are related to ischemia (insufficient blood flow). This procedure also identifies inducible wall motion abnormalities.
During the procedure, the patient undergoes continuous echo imaging at rest. The test continues during a full treadmill exercise protocol until the patient reaches the target heart rate. The physician supervises the entire test.
Here, CPT code 93351 applies.
Valvular Disease Severity Assessment
Consider a 73-year-old male patient with a known history of moderate aortic stenosis (AS) who visits the cardiologist for a follow-up. He complains of increased exertional dyspnea (shortness of breath) and fatigue over the last six months. However, the severity of the AS does not fully explain his symptoms at rest.
Thus, the cardiologist orders a physician-supervised transthoracic echocardiography both at rest and after exercise (CPT code 93351). During the procedure, the physician measures the aortic valve gradient (pressure difference) and the ventricular function at peak exercise.
The findings help the cardiologist determine whether the valve obstruction becomes significantly worse under physical load. If yes, the classification will change from moderate to severe, requiring surgical intervention.
Post-Myocardial Infarction Risk Stratification
Imagine a 52-year-old female patient who recently encountered a minor myocardial infarction (heart attack). Fortunately, she is stable now, but requires risk assessment before beginning an aggressive cardiac rehabilitation program.
Thus, the cardiologist orders a physician-assisted continuous TTE. The procedure employs a low-level exercise regimen. The physician reviews the images to evaluate ventricular performance at rest and under stress.
The findings help the cardiologist detect any residual ischemia or viability in the heart’s compromised areas. Besides, this enables him to determine the safety level for future exercise.
Here, CPT code 93351 applies.
Applicable Modifiers for CPT Code 93351
The following are some of the applicable modifiers related to the stress TTE procedure:
Modifier 26
What happens when you are a physician who conducted the interpretation of the images and prepared the report, but do not own or lease the equipment?
You append modifier 26 to CPT code 93351. It indicates that you are only billing for the professional component of continuous transthoracic echocardiography.
Modifier 52
There may be circumstances where the procedure is eliminated at the physician’s discretion without fulfilling all the components. For instance, during the stress portion of the test, the patient’s condition was not stable, and the physician called it off. When this happens, report modifier 52 with CPT code 93351 to indicate reduced services.
Modifier 59
What happens when the same physician performs the procedure covered under CPT code 93351 with another significant, separately identifiable procedure, such as 93303, 93304, 93306, 93307, or 93308 on the same day?
You append modifier 59 to prevent payment cuts due to bundling edits. However, you must support the medical necessity of the second procedure with a different diagnosis. That is, you cannot perform both services for the same diagnosis.
Modifier TC
Facilities that own the equipment, resources, and supplies typically bill for the technical component of the continuous transthoracic echocardiography. They do so by appending modifier TC to CPT code 93351.
CPT Code 93351 – Billing & Reimbursement Guidelines
Discussed below are the essential billing and reimbursement guidelines for stress TTE:
Demonstrate Medical Necessity
Establishing medical necessity is key to ensuring timely reimbursement. The following are some of the clinical indications for CPT code 93351:
- Assessment of unexplained dyspnea or shortness of breath on exertion.
- Evaluation of new or changing exertional chest pain.
- Functional result evaluation following coronary revascularization (CABG or PCI).
- Functional severity identification of valvular heart disease
- Pre-operative cardiac risk assessment for major non-cardiac surgery.
- Risk stratification after a heart attack.
Focus on Documentation Completeness
Note that your documentation must provide evidence that the physician provided the complete service described under the CPT code 93351 descriptor. Thus, your documentation must involve the following:
- Mention clearly that the physician was present for the entire stress phase of the test.
- Document the quality and acquisition of images at both rest and peak stress.
- Global and regional ventricular wall motion evaluation at both phases.
- Assessment of ejection fraction or other measures of ventricular function.
- State why (if) the test was terminated. For instance, target heart rate achieved, patient symptoms, or ECG changes.
Know When to Report Add-On Code 93352 with 93351
What happens when the provider administers a contrast agent intravenously to obtain enhanced images of the heart for a stress echocardiography? He reports this with a supplementary CPT code 93352.
Thus, you should report the add-on code 93352 in conjunction with the primary CPT code 93351 to highlight that the images are contrast-enhanced.
Do Not Report CPT Code 93351 with 93015
As per the National Correct Coding Initiative (NCCI) edits, CPT code 93015 is a column 2 code for 93351. Simply put, reimbursement for 93015 (plain stress ECG) is bundled into 93351. Thus, you cannot report both together.
Summary
With that said, it is time to conclude this guide. However, before we wrap up, let’s quickly recap everything that we discussed:
First, we explained the CPT code 93351 descriptor. It covers the complete physician-assisted stress TTE.
Next, we shared some of the real-world clinical scenarios. These include risk stratification following a heart attack, evaluation of angina pectoris, and assessment of valvular disease severity.
We listed some of the applicable modifiers for CPT 93351, including 26, 52, 59, and TC.
Finally, we discussed the essential billing and reimbursement guidelines.
Hopefully, this guide will become your go-to resource when billing for stress TTE procedures. However, if you still struggle to ensure timely reimbursements, outsource cardiology billing services to professionals like MediBillMD.
