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CPT 2009 brought significant changes for the reporting of Doppler echocardiography, and confusion continues to linger as to applying the correct coding for specific procedures. My goal with this article is to answer and bring clarification to any questions you may have regarding the coding of echocardiography.
 One important note before we begin: All echocardiography codes discussed in this article include the "global" service (that is, both professional and technical components). To report interpretation/report only, append modifier 26: Professional component.
CPT Simplifies Combo Service Coding
Doppler echocardiography uses reflected, high-frequency ultrasound to image the heart, with simultaneous application of the Doppler effect--which describes changes in a sound wave's movement relative to an observer--to determine the velocity and direction of blood flow through the heart and nearby vessels. Doppler echocardiography is a common diagnostic procedure employed to assess heart pumping function, valve action and chamber size, among other characteristics
However, prior to 2009, no single CPT code described transthoracic echocardiography with spectral Doppler, which displays flow velocity graphically, and color flow Doppler, which represents flow velocity using different colors (shades of red for flow moving toward the transducer; shades of blue for flow moving away from the transducer). Therefore, reporting such a study required coding for the echocardiography, along with separate add-on coding for the Doppler components.
CPT 2009 added a new, single code to capture all the work of complete echocardiography with spectral and color flow Doppler: 93306 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.
The Centers for Medicare and Medicaid Services (CMS) assigned a relative value unit (RVU) total of 7.42 for 93306 (fully implemented facility and non-facility totals). Although this value accounts for all elements of the service, it is lower than the combined RVUs of the three codes that previously described complete echocardiography with spectral and color flow Doppler. The American College of Cardiology (ACC) explained this reduction in payment by reasoning, "The new bundled codes for echocardiography result from intense pressure by the [CMS], Medicare Payment Advisory Commission and other policymakers to move toward combining codes for services frequently performed together. This initiative is fueled by the belief that the payment rates that result from having separate codes for services frequently performed together are too high and do not account for efficiencies in physician work and practice expense."
Also in 2009, the descriptor to CPT 93307 was revised to specify "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography [emphasis added]." Reporting complete transthoracic echocardiography, either without or without Doppler studies, now requires a single code in either case:
• 99306 for echocardiography with spectral and color Doppler
• 99307 for echocardiography without spectral and color Doppler.
Note that both of these services include M-mode recording when performed. That is, M-mode recording is not a required component of the service. When M-mode recording is performed, documentation should reflect the findings.
Limited vs. Complete Exams
Code 93308 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; follow-up or limited study describes follow-up or limited echocardiogram without spectral and color flow Doppler, including M-mode recording when performed. CPT Assistant (September 2005) explained that the provider may choose a follow up to a complete exam when, for instance, the patient only needs evaluation of a more focused area. Or, a limited exam may be chosen in certain emergent situations.
CPT defines a follow-up or limited echocardiographic study as an examination "that does not evaluate or document the attempt to evaluate all the structures that comprise the complete echocardiographic exam."
A complete exam, as defined by CPT, includes 2-dimensional and selected M-mode examination of the left and right atria; the left and right ventricles; the aortic, mitral, and tricuspid valves; the pericardium and adjacent portions of the aorta. Additional structures that may be visualized, such as the pulmonary veins and artery, pulmonic valve, and inferior vena cava, are included in the service.
Note that if the provider tries to, but cannot, identify and measure all required structures, he or she should document why those specific elements cannot be visualized, according to CPT's echocardiography guidelines. With the required documentation, a complete transthoracic echocardiogram (99306 or 99307, depending on whether spectral and color Doppler studies also were performed) may be reported. If documentation does not reflect attempted or actual exam of all the required structures, report a limited study (99308).
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