David L. Reich and Maria Galati

Introduction

In the United States, perioperative transesophageal echocardiography (TEE) is a procedure that is recognized for reimbursement by the Centers for Medicare and Medicaid Services (CMS) and many private medical insurance plans. These insurance plans will reimburse TEE separately from a concomitant anesthetic when it is reasonable and medically necessary, performed by a credentialed provider for diagnostic purposes, ^∗ and documented in a compliant manner.

This chapter will discuss the requirements for billing, collection, and compliance with guidelines for the reimbursement of TEE services in the current U.S. healthcare system. While many concepts are applicable to cardiology and intensive care unit settings, this chapter is focused on issues pertinent to anesthesiologists performing TEE in perioperative settings. CMS guidelines will be the primary source used in this discussion, because they often are followed in whole or in part in the payment policies of other insurance plans.

Local Carrier Determinations and Medical Necessity

CMS contracts with agents in the private sector, typically insurance companies, to administer Medicare program services such as physician claims administration. These intermediaries are known as Medicare “carriers.” Carriers are regionally based, and although they are charged with following National Coverage Determinations issued by CMS, there is room for local variation in interpreting and applying these guidelines. Carriers publish their own payment guidelines in “local carrier determinations” (LCDs) that define how national Medicare policy is applied within their geographic jurisdiction. Physicians, billing staff, and compliance advisors must consult their specific carrier’s LCDs in seeking counsel on reimbursement requirements for TEE; geographic variation in Medicare payment policy is possible.

The LCD (from the National Government Services [NGS] carrier) is paraphrased below as an example of Medicare policy on medical necessity for TEE: ¹

Additionally, TEE is considered superior to TTE in certain cases. Medicare considers TEE appropriate for detecting specific pathophysiologic conditions involving the aorta and the posterior structures of the heart (e.g., left atrium, mitral valve, pulmonary veins, etc.) Carriers will list in their LCDs the medical conditions they deem to be “covered” as indications for TEE ( Box 31-1). These indications are derived from evidence in the medical literature. Inclusion of the appropriate diagnosis codes in support of claims is one essential element for reimbursement of TEE services.

TEE technology is evolving, and there is continual improvement in diagnostic capabilities, especially with the introduction of three-dimensional (3D) TEE, tissue Doppler imaging, and speckle tracking. Medicare recognizes several indications for the use of 3D technology when billed with TEE, including preoperative and intraoperative planning of procedures of the mitral valve and atria, complex repair of congenital heart disease, and for related interventional cardiac procedures. However, not all carriers consider newer applications of TEE such as 3D TEE as “medically necessary.” The NGS carrier asserts that the value of 3D TEE in affecting clinical outcomes is not yet proven and therefore is not “medically necessary.” ¹ Other carriers, such as Wisconsin Physicians Service Insurance Corporation, consider it medically necessary under certain conditions where the referring physician documents the clinical need for 3D imaging in a written request to the interpreting physician, who in turn addresses those clinical issues in the report and maintains a copy of the request. ² This carrier adds stipulations requiring assignment of eligible diagnosis codes and assurance that equivalent information has not already been provided or could be provided by another procedure.

In summary, medical necessity determinations are a matter of local carrier policy and are subject to many stipulations and requirements that must be in evidence in the claims submission and medical record documentation processes.

Provider Training and Credentialing

The New York City area Medicare carrier revised its LCD on TEE in 2005 to include requirements for provider competence and credentialing as a component of its medical necessity determination. ³ The argument for these changes was that substandard studies led to unnecessary duplication and overutilization of TEE services. Since 2005, training and credentialing requirements have been updated, and providers in this jurisdiction were given until July 1, 2011, to comply with the following levels of competence or face denial of claims for the professional portion of the TEE procedure:

An acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting any one of the following requirements:

• The physician is board certified in Cardiovascular Diseases or Perioperative Transesophageal Echocardiography (National Board of Echocardiography); or

• The physician has Level II training in transesophageal echocardiography (including documentation of the performance of 25 esophageal intubations and 50 supervised interpretations), as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, or the equivalent of Level II training as set forth in that document.

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