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American Society of Echocardiography Coding and Reimbursement Newsletter

January 2009

The ASE Coding and Reimbursement Newsletter is a biannual resource for cardiovascular ultrasound procedures. This newsletter and the opportunity to have our coding consultant answer coding questions are information resources provided exclusively to members of ASE. Judy Rosenbloom, president of JR Associates, provides these services. For questions or comments write to [email protected]

New Echocardiography Codes and Descriptions for 2009

To help members prepare for the new CPT coding year beginning on January , 2009, here are the highlights of the major code changes that will affect echocardiography services. See Tables & 2 for details. In some cases, the new code is only applicable for a specific site of service (hospital or office). At the time of this printing, ASE notes that further explanation from CMS is needed to better understand how to report the new bundled stress echo codes and stress test when provided in the hospital setting. ASE is also seeking clarification from the AMA about the use of transthoracic (TTE) code 93307 with spectral or color Doppler. As soon as the information becomes available, ASE will notify members. - Replaces the combined reporting of both codes 93350 and 9305 when done in the office setting. - Cannot be reported with stress test codes 93059308. · Addition of an add-on code 93352 to report the administration of a contrast agent during a stress echo. - May be reported with 93350 or 9335. - May only be reported once per stress echo. · Two new hospital HCPCS codes (C8929, C8930) were added by CMS to parallel the new 2009 CPT codes: 93306, combined echo, spectral Doppler with color Doppler, and 9335, combined stress test and stress echo when provided with contrast. CPT Manual Guidelines and Definitions: · The Echocardiography Introduction sections in the CPT manual have been modified to describe, in greater detail, the various components of echocardiography procedures. · Codes 93307, 93308 and 93350 descriptors are revised for consistency with current CPT nomenclature to indicate "includes M-mode recording, when performed."

New Codes: (see Table 1 & 2)

Transthoracic echocardiography: · Addition of code 93306 as a comprehensive service to report the combined components of 2D, spectral and color flow Doppler studies. Stress echocardiography: · Addition of code 9335 to report the combined service of a stress echocardiogram with a stress test. - Applicable to a single provider who provides this exam in the office (non-facility) setting.

Table 1. Description of Echocardiography CPT Code Changes

CPT CODE 93306 CHANGE New Code DESCRIPTOR AND MODIFICATIONS Echocardiography, transthoracic real-time with image documentation (2-D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography BILLING GUIDANCE Report when 2D, spectral Doppler, and color Doppler are combined during a single session. Replaces separate reporting of codes 93307 (2D), 93320 (spectral Doppler), and 93325 (color) when performed at a single session. Report when a complete 2D exam is performed. AMA CPT guidance states, "Do not report 93307 in conjunction with 93320, 9332, 93325." See endnote i. Report for a follow up or focused clinical 2D exam. Applicable for all sites of hospital (i.e. hospital, physician office). SITE OF SERVICE Applicable for all sites of service (i.e. hospital, physician office).

93307

Descriptor Modified

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

93308

Descriptor Modified

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2D), includes with or without M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically inducedstress, with interpretation and report;

Applicable for all sites of hospital (i.e. hospital, physician office). Applicable for all sites of hospital (i.e. hospital, physician office).

93350

Descriptor Modified

The appropriate stress test codes (9306-9308) should also be reported with 93350 to capture the exercise portion of the stress echo. Do not report 93350 when the stress echo and stress test are provided by the same physician in the physician office. See code 9335. Report when a stress ECG and stress echo are performed by the same physician in the physician office. Replaces reporting CPT 9305 and 93350. Established as a global code, which includes both physician and technical components. AMA guidance states: "Do not report 9335 in conjunction with 9305-9308." Report when contrast is performed with stress echo. Do not report more than once per stress echo May be reported with 93350, 9335. Report separately for the contrast agent itself, using the appropriate HCPCS code (HCPCS code Q9955,Q9956 or Q9957) See endnote iii.

9335 See endnote ii.

New Code

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test pharmacologically induced stress, with interpretation and report: including performance of continuous electrocardiographic monitoring, with physician supervision

Applicable in the physician office. Hospital code use is unclear. See endnote ii.

93352

New Code

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

Applicable only in the physician office setting.

2

Table 2. Description of New Echocardiography Hospital Only HCPCS Codes

HCPCS CODE C8929 CHANGE New Code DESCRIPTOR Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography BILLING GUIDANCE Report for a contrast-enhanced TTE with color and spectral Doppler Report separately for the contrast agent itself, using the appropriate HCPCS code (HCPCS code Q9955,Q9956 or Q9957) Report for a combined contrast-enhanced stress ECG/stress echo. Report separately for the contrast agent itself, using the appropriate HCPCS code (HCPCS code Q9955,Q9956 or Q9957) Applicable only for hospital reporting of outpatient procedures. See endnote iv. SITE OF SERVICE Applicable only for hospital reporting of outpatient procedures.

C8930

New Code

Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, 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

2009 Physician Payments (Medicare Physician Fee Schedule)

Medicare reimburses physicians based on a Resource Based Relative Value System (RBRVS) fee schedule. Under this system, payments are based on weights, called relative value units (RVUs). These values account for the relative costs of the resources used to provide the service: physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined values by a conversion factor (a monetary amount determined by CMS). Payments are also adjusted for geographical differences in resource costs. The conversion factor is updated annually and influences whether payments rise or fall. The conversion factor for 2009 will be reduced by approximately $2 from the 2008 conversion factor due to a number of technical factors including the enactment of "Medicare Improvements for Patients and Providers Act of 2008" (MIPPA) legislation and the elimination of a work neutrality adjustment. In addition, practice expense RVUs are further reduced to reflect year three of previously mandated transitional reductions which will be fully implemented by 200. These policies and the establishment of new echocardiography codes have resulted in various payment changes. Table 3 (begins on p.4) compares the difference of payments from 2008 to 2009.

3

Table 3 - CY 2008 Comparison to 2009 Physician Fee Schedule Medicare Payments

DESCRIPTION CPT CODE & MODIFIER 2008 PAYMENT 2009 PAYMENT $$$ DIFF %%% DIFF

3 DIMENSIONAL RENDERING

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 76376 -26 -TC 76377 -26 -TC $04 $0 $94 $38 $40 $98 $80 $ $69 $4 $42 $7 -$24 $ -$25 -$24 $2 -$27 -23% 8% -26% -7% 5% -27%

ECHOCARDIOGRAM, FETAL HEART

Echocardiography, fetal, cardiovascular system, real-time with image documentation (2D) with or without M-mode recording; complete Echocardiography, fetal, cardiovascular system, real-time with image documentation (2D) with or without M-mode recording; follow up or repeat study Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study 76825 -26 -TC 76826 -26 -TC 76827 -26 -TC 76828 -26 -TC $95 $80 $5 $02 $39 $63 $82 $27 $54 $60 $27 $33 $207 $83 $24 $4 $40 $74 $72 $28 $44 $53 $28 $26 $2 $3 $9 $2 $ $ -$0 $ -$0 -$7 $ -$7 6% 3% 8% 2% 4% 7% -2% 6% -9% -% 3% -22%

ECHOCARDIOGRAM, 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 NEW CODE 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 physician supervision NEW CODE Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure) 93350 -26 -TC $98 $77 $2 $22 $80 $3 $4 $3 $0 7% 4% 8%

9335

------

$277

------

------

93352

------

$39

------

------

STRESS TEST

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report. Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report. Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only 9305 $04 $00 -$4 -4%

9306

$24

$25

$

2%

9307

$66

$60

-$6

-0%

9308

$5

$6

$

8%

4

Table 3 - CY 2008 Comparison to 2009 Physician Fee Schedule Medicare Payments (continued from page 4)

DESCRIPTION CPT CODE & MODIFIER 2008 PAYMENT 2009 PAYMENT $$$ DIFF %%% DIFF

ECHOCARDIOGRAM, TRANSESOPHAGEAL ­ ADULT AND CONGENITAL

Transesophageal echocardiography (TEE) real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Transesophageal echocardiography (TEE) real time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only. Transesophageal Echocardiography (TEE) real time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only. Transesophageal Echocardiography (TEE) for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transesophageal Echocardiography (TEE) for congenital cardiac anomalies; placement of transesophageal probe only. Transesophageal Echocardiography (TEE) for congenital cardiac anomalies; image acquisition, interpretation and report only. Echocardiography, 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. 9332 -26 -TC 9333 9334 -26 -TC 9335 -26 -TC 9336 9337 -26 -TC 9338 -26 -TC $36 $0 $205 $4 $273 $63 $20 $0 $4 $0 $43 $0 $88 $0 $0 $05 $0 $326 $6 $20 $4 $280 $66 $25 $0 $49 $0 $45 $0 $92 $0 $0 $3 $0 $0 $6 $5 $0 $7 $3 $5 $0 $8 $0 $2 $0 $4 $0 $0 $8 $0 3% 6% 2% % 3% 4% 2% 0% 5% 0% 6% 0% 5% 0% 0% 8% 0%

ECHOCARDIOGRAM, TRANSTHORACIC ­ ADULT AND CONGENITAL

Transthoracic echocardiography (TTE) for congenital cardiac anomalies; complete Transthoracic echocardiography (TTE) for congenital cardiac anomalies; follow-up or limited study NEW CODE 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 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study 93303 -26 -TC 93304 -26 -TC 93306 -26 -TC 93307 -26 -TC 93308 -26 -TC $222 $64 $58 $33 $37 $96 ---------------$92 $47 $45 $4 $27 $87 $28 $69 $49 $35 $39 $96 $268 $72 $96 $77 $50 $27 $2 $29 $83 -$4 $5 -$9 $2 $2 $0 $0 $0 $0 -$5 $3 -$8 -$2 $2 -$4 -2% 8% -5% % 5% 0% 0% 0% 0% -8% 6% -2% -2% 8% -5%

DOPPLER

Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete. Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study. Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiographic imaging) 93320 -26 -TC 9332 -26 -TC 93325 -26 -TC $85 $9 $66 $42 $8 $34 $79 $4 $75 $78 $2 $58 $35 $8 $27 $54 $4 $50 -$7 $2 -$8 -$7 $0 -$7 -$25 $0 -$25 -8% 8% -3% -7% 4% -22% -32% -% -33%

5

Table 3 - CY 2008 Comparison to 2009 Physician Fee Schedule Medicare Payments (continued from page 5)

DESCRIPTION CPT CODE & MODIFIER 2008 PAYMENT 2009 PAYMENT $$$ DIFF %%% DIFF

CONTRAST

Perflexane Lipid microspheres, per ml Q9955 Average Sales Price Calculation Average Sales Price Calculation Average Sales Price Calculation Average Sales Price Calculation Average Sales Price Calculation Average Sales Price Calculation -----------

Octafluoropropane microspheres, per ml

Q9956

------

------

Perflutren lipid microspheres, per ml

Q9957

------

------

ABDOMINAL AORTIC ANEURYSM (AAA) SCREENING

Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening G0389 -26 -TC $5 $28 $87 $ $30 $8 -$4 $2 -$6 -3% 8% -7%

ABDOMINAL DUPLEX ­ AORTA, IVC, ILIAC, BYPASS GRAFTS

Duplex scan of aorta, inferior vena cava, iliac vasculature or bypass grafts; complete study Duplex scan of aorta, inferior vena cava, iliac vasculature or bypass grafts; unilateral or limited study 93978 -26 -TC 93979 -26 -TC $239 $32 $207 $66 $22 $44 $239 $34 $205 $65 $22 $42 $0 $2 -$2 -$ $0 -$2 0% 5% -% -% 2% -%

ABDOMINAL DUPLEX ­ ARTERIAL INFLOW/VENOUS OUTFLOW

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93975 -26 -TC 93976 -26 -TC $388 $89 $299 $224 $58 $65 $378 $93 $285 $28 $6 $57 -$0 $4 -$4 -$6 $3 -$8 -2% 5% -5% -3% 6% -5%

ARTERIAL - UPPER AND LOWER EXTREMITIES

Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia) Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93922 -26 -TC $25 $2 $2 $20 $3 $08 -$5 $ -$4 -4% 5% -4%

93923 -26 -TC 93924 -26 -TC 93925 -26 -TC 93926 -26 -TC

$9 $22 $69 $232 $25 $207 $36 $28 $288 $98 $9 $79

$86 $23 $63 $229 $26 $203 $308 $30 $279 $97 $20 $77

-$5 $ -$6 -$3 $ -$4 -$8 $2 -$9 -$ $ -$2

-3% 5% -4% -% 5% -2% -2% 6% -3% -% 6% -%

6

Table 3 - CY 2008 Comparison to 2009 Physician Fee Schedule Medicare Payments (continued from page 6)

DESCRIPTION CPT CODE & MODIFIER 2008 PAYMENT 2009 PAYMENT $$$ DIFF %%% DIFF

ARTERIAL - UPPER AND LOWER EXTREMITIES (continued)

Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93930 -26 -TC 9393 -26 -TC $252 $23 $229 $66 $5 $5 $244 $24 $220 $63 $6 $48 -$8 $ -$9 -$3 $ -$3 -3% 3% -4% -2% 6% -2%

CEREBROVASCULAR EXAM ­ EXTRACRANIAL

Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis) Duplex scan of extracranial arteries; complete bilateral study 93875 -26 -TC 93880 -26 -TC 93882 -26 -TC $05 $0 $94 $258 $29 $229 $69 $20 $49 $0 $ $90 $248 $3 $27 $64 $2 $43 -$4 $ -$4 -$0 $2 -$2 -$5 $ -$6 -3% 2% -4% -4% 7% -5% -3% 3% -4%

Duplex scan of extracranial arteries; unilateral or limited study

HEMODIALYSIS SHUNT

Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow) (Medicare only) 93990 -26 -TC G0365 -26 -TC $94 $3 $8 $93 $2 $8 $93 $3 $80 $93 $2 $80 -$ $0 -$ $0 $0 -$ -% -3% 0% 0% 2% 0%

TRANSCRANIAL DOPPLER

Transcranial Doppler study of the intracranial arteries; complete study 93886 -26 -TC 93888 -26 -TC 93890 -26 -TC 93892 -26 -TC 93893 -26 -TC $3 $46 $265 $207 $3 $76 $267 $50 $27 $284 $56 $229 $285 $56 $229 $298 $47 $25 $203 $32 $7 $262 $50 $22 $287 $57 $230 $286 $57 $229 -$3 $ -$4 -$4 $ -$5 -$5 $0 -$5 $3 $ $ $ $ $0 -4% 3% -5% -2% 4% -3% -2% 0% -2% % 2% 0% 0% 2% 0%

Transcranial Doppler study of the intracranial arteries; limited study

Transcranial Doppler study of the intracranial arteries; vasoreactivity study

Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection

7

Table 3 - CY 2008 Comparison to 2009 Physician Fee Schedule Medicare Payments (continued from page 7)

DESCRIPTION CPT CODE & MODIFIER 2008 PAYMENT 2009 PAYMENT $$$ DIFF %%% DIFF

VENOUS EXTREMITIES

Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93965 -26 -TC 93970 -26 -TC 9397 -26 -TC $28 $7 $ $259 $34 $225 $73 $22 $50 $23 $8 $05 $254 $35 $29 $68 $23 $45 -$5 $ -$6 -$5 $ -$6 -$5 $ -$5 -4% 4% -5% -2% 3% -3% -3% 5% -3%

Examples of 2009 Code Use ­ Physicians

Table 4 - Physician Reporting

PROCEDURE TTE with spectral Doppler and color Doppler GLOBAL - (IN OFFICE) 93306 FACILITY - (HOSPITAL SETTING) 93306-26

Stress Echo with Stress Test

9335

93350-26 9306 9308 93350-26 9306 9308 93352 Applicable Q code

Stress Echo with Stress Test with Contrast

9335 93352

2009 Medicare Hospital Outpatient Payments

Outpatient procedures and services are reimbursed by Medicare under the Outpatient Prospective Payment System (OPPS), whereby services are assigned to an Ambulatory Payment Classification (APC). Services in each APC are clinically similar and generally require similar resources. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter. The OPPS utilizes CPT and HCPCS procedure codes to report services and is a cost based payment system. The final rates for calendar year 2009 were released in November with implementation January , 2009. See Table 5 (begins on next page).

8

Table 5 - CY 2008 Comparison to 2009 Hospital Outpatient Medicare Payments

DESCRIPTION CPT CODE 2008 APC PAYMENT 2009 APC PAYMENT $$$ DIFF %%% DIFF

3 DIMENSIONAL RENDERING

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 76376* $0 $0 $0 ------

76377*

$0

$0

$0

------

ECHOCARDIOGRAM, FETAL HEART

Echocardiography, fetal, cardiovascular system, real-time with image documentation (2D) with or without M-mode recording; complete Echocardiography, fetal, cardiovascular system, real-time with image documentation (2D) with or without M-mode recording; follow up or repeat study Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study 76825 $96 $43 $335 349%

76826 76827 76828

$6 $6 $6

$255 $63 $63

$94 $2 $2

38% 2% 2%

ECHOCARDIOGRAM, 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; NEW CODE 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 physician supervision NEW CODE Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure) 93350 $406 $43 $25 6%

9335

------

$43

------

------

93352**

------

$0

------

------

STRESS TEST

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report. 9307 $63 $7 $8 5%

ECHOCARDIOGRAM, TRANSESOPHAGEAL ­ ADULT AND CONGENITAL

Transesophageal Echocardiography (TEE) real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Transesophageal Echocardiography (TEE) real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only. 9332 $523 $552 $29 5%

9333

$523

$552

$29

5%

9

Table 5 - CY 2008 Comparison to 2009 Hospital Outpatient Medicare Payments (continued from page 9)

DESCRIPTION CPT CODE 2008 APC PAYMENT 2009 APC PAYMENT $$$ DIFF %%% DIFF

ECHOCARDIOGRAM, TRANSESOPHAGEAL ­ ADULT AND CONGENITAL (continued)

Transesophageal Echocardiography (TEE) real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only.** Transesophageal Echocardiography (TEE) for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transesophageal Echocardiography (TEE) for congenital cardiac anomalies; placement of transesophageal probe only Transesophageal Echocardiography (TEE) for congenital cardiac anomalies; image acquisition, interpretation and report only.** Echocardiography, 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. 9334 $0 $0 $0 ------

9335 9336 9337

$523 $523 $0

$552 $552 $0

$29 $29 ------

5% 5% ------

9338

$523

$552

$29

5%

ECHOCARDIOGRAM, TRANSTHORACIC ­ ADULT AND CONGENITAL

Transthoracic echocardiography (TTE) for congenital cardiac anomalies; complete Transthoracic echocardiography (TTE) for congenital cardiac anomalies; follow-up or limited study NEW CODE 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 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study 93303 93304 $406 $23 $43 $255 $25 $42 6% 20%

93306

------

$43

------

------

93307

$406

$255

-$5

-37%

93308

$23

$255

$42

20%

DOPPLER

Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); complete. Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); follow-up or limited study. Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiographic imaging) 93320* $0 $0 $0 ------

9332* 93325*

$0 $0

$0 $0

$0 $0

-----------

CONTRAST

Perflexane Lipid microspheres, per ml Octafluoropropane microspheres, per ml Perflutren lipid microspheres, per ml Q9955* Q9956* Q9957* $0 $0 $0 $0 $0 $0 -------------------------------

0

Table 5 - CY 2008 Comparison to 2009 Hospital Outpatient Medicare Payments (continued from page 10)

DESCRIPTION CPT CODE 2008 APC PAYMENT 2009 APC PAYMENT $$$ DIFF %%% DIFF

ECHOCARDIOGRAPHY WITH CONTRAST

Transthoracic Echocardiogram with contrast for congenital cardiac anomalies; complete Transthoracic Echocardiogram with contrast for congenital cardiac anomalies; follow-up or limited study Transthoracic Echocardiogram with contrast, real-time with image documentation (2D) with or without M-Mode recording; complete Transthoracic Echocardiogram with contrast, real-time with image documentation (2D) with or without M-Mode recording; follow-up or limited study Transesophageal Echocardiogram (TEE) with contrast, real-time with image documentation (2D) with or without M-Mode recording; including probe placement, image acquisition, interpretation and report Transesophageal Echocardiogram (TEE) with contrast for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transesophageal Echocardiogram (TEE) with contrast for monitoring purposes; including probe placement, real time 2D image acquisition and interpretation leading to continuous assessment of cardiac pumping function and to therapeutic measure on an immediate time basis Transthoracic Echocardiogram (TTE) with contrast, real-time image documentation (2D) with or without M-Mode recording; during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report NEW CODE Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography NEW CODE Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, 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 C892 C8922 C8923 $54 $54 $54 $566 $566 $566 $25 $25 $25 5% 5% 5%

C8924

$54

$566

$25

5%

C8925

$54

$566

$25

5%

C8926

$54

$566

$25

5%

C8927

$54

$566

$25

5%

C8928

$54

$566

$25

5%

C8929

------

$566

------

------

C8930

------

$566

------

------

ABDOMINAL AORTIC ANEURYSM (AAA) SCREENING

Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening G0389 $96 $98 $2 2%

ABDOMINAL DUPLEX ­ AORTA, IVC, ILIAC, BYPASS GRAFTS

Duplex scan of aorta, inferior vena cava, iliac vasculature or bypass grafts; complete study Duplex scan of aorta, inferior vena cava, iliac vasculature or bypass grafts; unilateral or limited study 93978 93979 $52 $96 $53 $98 $ $2 % 2%

ABDOMINAL DUPLEX ­ ARTERIAL INFLOW/VENOUS OUTFLOW

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93975 93976 $52 $52 $53 $53 $ $ % %

Table 5 - CY 2008 Comparison to 2009 Hospital Outpatient Medicare Payments (continued from page 11)

DESCRIPTION CPT CODE 2008 APC PAYMENT 2009 APC PAYMENT $$$ DIFF %%% DIFF

ARTERIAL - UPPER AND LOWER EXTREMITIES

Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia) Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93922 $94 $95 $ %

93923

$94

$95

$

%

93924 93925 93926 93930 9393

$94 $52 $96 $52 $96

$95 $53 $98 $53 $98

$ $ $2 $ $2

% % 2% % 2%

CEREBROVASCULAR EXAM ­ EXTRACRANIAL

Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis) Duplex scan of extracranial arteries; complete bilateral study Duplex scan of extracranial arteries; unilateral or limited study 93875 93880 93882 $94 $52 $52 $95 $53 $53 $ $ $ % % %

HEMODIALYSIS SHUNT

Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow) (Medicare only) 93990 $96 $98 $2 2%

G0365

$52

$53

$

%

TRANSCRANIAL DOPPLER

Transcranial Doppler study of the intracranial arteries; complete study Transcranial Doppler study of the intracranial arteries; limited study Transcranial Doppler study of the intracranial arteries; vasoreactivity study Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection 93886 93888 93890 93892 93893 $52 $6 $96 $96 $96 $53 $63 $98 $98 $98 $ $2 $2 $2 $2 % 2% 2% 2% 2%

2

Table 5 - CY 2008 Comparison to 2009 Hospital Outpatient Medicare Payments (continued from page 12)

DESCRIPTION CPT CODE 2008 APC PAYMENT 2009 APC PAYMENT $$$ DIFF %%% DIFF

VENOUS EXTREMITIES

Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93965 93970 $94 $52 $95 $53 $ $ % %

*Codes 76376, 76377, 93320, 9332, 93325, 9334, and 9337 are packaged under OPPS and are not reimbursed separately by Medicare. ** Code 93352 is not paid in the hospital setting under OPPS. (Hospitals, see C8928 or C8930 and endnote iv).

Examples of 2009 Code Use - Hospitals

Table 6 - Hospital Reporting

PROCEDURE TTE with Doppler and color Doppler Stress Echo with Stress Test Stress Echo with Stress Test with Contrast HOSPITAL OUTPATIENT 93306 Requires clarification; see endnote ii Requires clarification; see endnote ii-v Applicable Contrast "Q" code

Hospital Alert: Packaged Payments Should Still Be Reported!

Medicare's designation of packaged CPT and HCPCS codes (i.e. 93320, 9332, 93325, 76376, 76377, Q9954-Q9956, etc.) does not mean hospitals should not assign charges to those codes. Rather those codes should be reported as their charges factor into future rate setting by Medicare. If the charges are not captured in the claims data, future Medicare payments for the primary procedures that these codes are packaged into (i.e. stress echo, TEE, congenital echo, etc.) could be reduced. See endnote vi. In addition, hospitals should continue to charge for these packaged codes because other non-Medicare payers may pay separately for those services (codes).

3

Source Documents

· 2009 CPT Professional Edition · CMS-404-FC - November 2008 Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2009 Payment Rates · November 2008: Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009 This newsletter is for information purposes only. No guarantee of payment is stated or implied. It is the responsibility of the health care provider to properly code and to seek reimbursement for rendered medically appropriate and necessary services. CPT copyright 2007 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association Applicable FARS/DFARS Restrictions Apply to Government Use Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not par of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Endnotes

i. This CPT instruction doesn't reflect the intent of allowing 93307 to be reported with either spectral Doppler or color Doppler. ASE will address this with the AMA. ii. It is unclear at the time of this printing whether hospitals should use CPT code 9335 to report a stress ECG and stress echo or whether they should continue to report CPT 9307 and 93350. Generally, the Hospital Outpatient Prospective Payment System (HOPPS) does not classify global codes into APCs or designate an APC payment rate for them. However, in the final rule, CMS assigned an APC payment to CPT Code 9335--the same amount payable for stress echo (CPT 93350) alone. ASE is submitting comments to CMS, requesting the agency to clarify that hospitals are to continue to bill for CPT Codes 9307 and 93350 for ECG/Stress echo, rather than using the new CPT Code 9335. iii. Per CMS Transmittal 487, April 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS): Cardiac Echocardiography With Contrast: Hospitals are reminded that these codes should be reported for echocardiograms with contrast, and hospitals are advised to report the appropriate units of the HCPCS codes for the contrast agents used in the performance of the echocardiograms. The contrast HCPCS Q-codes associated with these services should be reported separately. iv. It is unclear at the time of this printing in what circumstance C8930 should be reported and whether stress test code 9307 is to be reported in combination with C8930. v. Report separately the contrast agent itself, using the appropriate HCPCS code (Q9955,Q9956 or Q9957) vi. Medicare Claims Processing Manual: Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS): If a claim contains services that result in an APC payment but also contains packaged services, separate payment for the packaged services is not made since payment is included in the APC. However, charges related to the packaged services are used for outlier and Transitional Corridor Payments (TOPs) as well as for future rate setting.

4

American Society of Echocardiography Advocacy Update

January 2009

As we look toward a new year, amid myriad economic and legislative uncertainties, we wanted to take a moment to remind you that the ASE Advocacy team, comprised of our Advocacy Committee, led by Chairman Ben Byrd, MD, Co-chairs Mike Picard, MD and Elizabeth McIlwain, MHS, RDCS, and supported by our legislative counsel, Diane Millman, coding and reimbursement consultant Judy Rosenbloom, and office staff Cathy Kerr and Adrienne Coats, has been working hard for you and your practice on a number of fronts.

· ASE played a critical role in obtaining modification of FDA "black box" warning. ASE funded and published a multicenter contrast safety registry data in JASE. · ASE requested that CMS lift a National Correct Coding Initiative (CCI) edit that currently precludes separate Medicare payment for contrast administration in the non-hospital setting. · Regulation of Echo: ASE spearheaded an initiative to deter CMS from imposing new anti-markup rules on echo and other diagnostic tests that would have precluded Stark-Law compliant group practices from providing these services unless certain additional requirements were met. As the result of this initiative, CMS scaled back substantially on its proposal.

Efforts spearheaded by the ASE resulted in a number of victories in 2008

Payment for Echo Procedures in 2008

· ASE maintained separate Medicare payment for color flow Doppler in non-hospital settings (Estimated impact: $76/procedure.) · ASE convinced CMS to nearly double Medicare payment to hospitals for facility costs for stress echo over the amount proposed (Estimated impact: $9/procedure.) · ASE mobilized grassroots network to oppose further imaging cuts, 0% reduction in Physician Fee Schedule payments (SGR). Estimated impact: Approx. $45/procedure (TTE, spectral, color Doppler)

Quality-related initiatives

Quality has been an ongoing focus for ASE as an organization, and in 2008: · ASE funded a study of potential impact of echo appropriateness guidelines. · ASE advocated use of accreditation in lieu of prior certification, resulting in delay of Aetna's pre-certification program and modifications in United Healthcare/CareCore reimbursement policies. · ASE met with private payer medical directors as part of the ACC Medical Directors' Institute to address private payer initiatives to reduce echo utilization. · ASE supported enactment of CARE bill, which would mandate certification of cardiac sonographers. · ASE worked in collaboration with other organizations to ensure that the interests of cardiac sonographers are reflected in draft Oregon state licensure legislation that would require state licensure of sonographers.

continued on next page

Payment and Regulation of Echo Contrast in 2008

Last year was a challenging one for contrast, as the FDA had placed a "black box" warning on it in the spring. ASE was successful in its efforts to: · ASE obtained separate payment for contrast-enhanced echo procedures performed in hospital outpatient departments in 2008 (Estimated Impact: $30/procedure.)

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2009 ASE Coding and Reimbursement Newsletter

·

January 2009

Advocacy Update (continued from page 15)

· 38 ASE members and staff attended the September ACC Legislative Conference, at which quality and access to healthcare were issues; efforts were more about relationship-building and emphasizing our commitment to quality than lobbying for specific legislation. The Advocacy Committee is well aware of the value sonographers bring to the lobbying effort, and will plan to sponsor their attendance in the future. commonly performed together, the continued transition to "resource-based" practice expense payments, changes in CMS budget neutrality adjustments and other factors. Medicare payment for stress ECG/Stress echo when performed by the same physician also will be subject to "bundling." On the positive side, ASE's involvement was critical in obtaining a new CPT code for the administration of contrast in conjunction with stress echo and in increasing hospital outpatient rates for fetal echo. Over the coming year, ASE will continue to represent the interests of the cardiovascular ultrasound community in meetings with CMS and on the Hill. We look forward to future success--and unanticipated challenges--in 2009.

What's coming in 2009?

Echocardiography has been targeted by CMS because of the growth and utilization of the echo procedures. Unfortunately, Medicare payment for TTE performed in conjunction with spectral and color Doppler will be reduced substantially in 2009 due to "bundling" of codes

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