TEE BASIC - should I care about this?

[ToKingdomCome]

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I’m doing an ICU fellowship. I think TEE is a great tool. I Don’t really want to do hearts. I know there is utility in the ICU setting but does TEE basic certification itself really add any value outside of cardiac ?

 

[sevoflurane]

Yes. It does.
Especially if you are taking care of patients in the CT icu.
AVR/MVR codes at 10 pm on POD zero.
You do CPR for 5 minutes.
You are going to want to do a TEE and assess any possible damage.

Coming from someone who holds both basic and advanced certifications, the basic actually covers a ton of material. I think i would feel comfortable doing a lot in the ICU with just the basic. My 2cents.

 

[ToKingdomCome]

Yes. It does.
Especially if you are taking care of patients in the CT icu.
AVR/MVR codes at 10 pm on POD zero.
You do CPR for 5 minutes.
You are going to want to do a TEE and assess any possible damage.

Coming from someone who holds both basic and advanced certifications, the basic actually covers a ton of material. I think i would feel comfortable doing a lot in the ICU with just the basic. My 2cents.

But is it worth it to get that piece of paper or can I just place the TEE probe in the ICU just to get fundamental pathologies ?

 

[sevoflurane]

I’m doing an ICU fellowship. I think TEE is a great tool. I Don’t really want to do hearts. I know there is utility in the ICU setting but does TEE basic certification itself really add any value outside of cardiac ?

Outside of cardiac TEE is useful for a ton of other stuff. Pleural/cariac effusions, low ef, endocarditis, eval LAA in someone who is in rapid afib, etc.

As for certification, it meets a minimal standard. Depending on where you train and how many TEE’s you do the basic actually gets you up to par or is just another feather in your hat.

 

[ToKingdomCome]

Outside of cardiac TEE is useful for a ton of other stuff. Pleural/cariac effusions, low ef, endocarditis, eval LAA in someone who is in rapid afib, etc.

As for certification, it meets a minimal standard. Depending on where you train and how many TEE’s you do the basic actually gets you up to par or is just another feather in your hat.

I guess I’ll try to go for the basic certification during fellowship then

 

[sevoflurane]

I would bud. Some hospital systems won’t let you drive a probe without at least a basic certification and it’s a great way to learn TEE during your fellowship (studying for the exam).

 

[Katheudontas parateroumen]

I am going for the Basic cert. It really should not be hard to get during the ICU year. Depending on your residency numbers, you could easily hit the numbers after a month of TEE as an elective. The basic exam has a 90+% pass rate as well. So useful information, knowledge, and not much more extra work than you're already doing during ICU fellowship. Depending on what practice I join, I was going to study for Advanced exam at some point as well.

 

[ToKingdomCome]

I’m

I am going for the Basic cert. It really should not be hard to get during the ICU year. Depending on your residency numbers, you could easily hit the numbers after a month of TEE as an elective. The basic exam has a 90+% pass rate as well. So useful information, knowledge, and not much more extra work than you're already doing during ICU fellowship. Depending on what practice I join, I was going to study for Advanced exam at some point as well.

ugh
Problem is I didn’t log any during residency…

 

[D P356]

Get the cert if you can get the numbers. Like Sevo said, it’s another feather in your cap. Especially in ICU where you could use it regularly.

When I was in training I enjoyed learning TEE. Didn’t get numbers to get basic cert. I was getting “experience” in other cases while on my TEE month…aka not enough warm bodies.

When I’m providing the anesthetic for a cath lab TEE, I enjoy talking with the cardiologist during their exam. TTE/POC ultrasound is something I’d like to learn for my own professional development.

To my knowledge major metropolitan areas where hospitals perform cardiac surgery are preferring fellowship trained and/or advanced/testamur TEE cert.

I think (?) in 2010 (correct me if I’m wrong) the door closed on getting the advanced TEE cert unless you go to fellowship. My guess is there will be a shortage of advanced TEE certified docs (more older grandfathered docs retiring vs fellows graduating), and some hospitals will start loosening the advanced certification and fellowship requirements.
I could be wrong and have been before.

Personally, with reviewing educational materials I feel I could still at least get through a basic pump case were there such a thing. But I see that as a huge disservice to the patient, so I don’t do pump cases.

 

[USCTrojan11]

Just keep in mind, this came up when I applied for jobs, that if you are covering cardiac, the basic cert actually certified you at a lower level than the advanced tee that fellowship trained cardiac folks get. This prevented billing for tee in a certain state and they said that if you plan to cover hearts without a fellowship, do not get basic certified. I can’t remember what state this applied to though. Weird that certifying at a low level was worse than nothing at all but we don’t make the billing rules.

 

[vector2]

Just keep in mind, this came up when I applied for jobs, that if you are covering cardiac, the basic cert actually certified you at a lower level than the advanced tee that fellowship trained cardiac folks get. This prevented billing for tee in a certain state and they said that if you plan to cover hearts without a fellowship, do not get basic certified. I can’t remember what state this applied to though. Weird that certifying at a low level was worse than nothing at all but we don’t make the billing rules.

Although I suppose anything's possible, I've never heard of a state level prohibition on which physicians can and can't bill for TEE, and I find it hard to imagine that anyone is actually auditing the credentials of every single person who files for a 99312 CPT code. What the payors actually require is that the pt has an indication and one placed the probe, performed the exam, acquired images, and filed a written exam interpretation. The ability to perform TEE and the level CPT code at which it's billed is usually controlled at the hospital administration level when you are initially privileged.

That being said, I'd recommend any critical care fellow to take the CCEeXAM and become certified, or if your program has enough elective time for TEE and you plan to have primarily CTICU as your practice, try to get the numbers to get advanced PTE certified. I suspect that going forward, more and more hospitals are going to put restrictions on who can and can't use the following ultrasound codes:

SCCM | Ultrasonography in Critical Care

Learn about billing and coding for ultrasonography in critical care.

www.sccm.org

 

[2Fast2Des]

I got the basic cert, have not touched a probe since residency.... Although it's a good CV stuffer. I'd need a warm-up to re-remember all the views though if I could ever do it again.

 

[ToKingdomCome]

Although I suppose anything's possible, I've never heard of a state level prohibition on which physicians can and can't bill for TEE, and I find it hard to imagine that anyone is actually auditing the credentials of every single person who files for a 99312 CPT code. What the payors actually require is that the pt has an indication and one placed the probe, performed the exam, acquired images, and filed a written exam interpretation. The ability to perform TEE and the level CPT code at which it's billed is usually controlled at the hospital administration level when you are initially privileged.

That being said, I'd recommend any critical care fellow to take the CCEeXAM and become certified, or if your program has enough elective time for TEE and you plan to have primarily CTICU as your practice, try to get the numbers to get advanced PTE certified. I suspect that going forward, more and more hospitals are going to put restrictions on who can and can't use the following ultrasound codes:

SCCM | Ultrasonography in Critical Care

Learn about billing and coding for ultrasonography in critical care.

www.sccm.org

I guess my goal will be to get the POCUS and TEE certifications.

I guess the exams never stop even with advance anesthesia exam in July….

 

[deleted87051]

The ability to perform TEE and the level CPT code at which it's billed is usually controlled at the hospital administration level when you are initially privileged.

In the real world, this means the chief of anesthesia or the chief of intensive care who will sign off your privileges if they need you. Nobody else has a clue or cares about what we do.

 

[potcake76]

Although I suppose anything's possible, I've never heard of a state level prohibition on which physicians can and can't bill for TEE, and I find it hard to imagine that anyone is actually auditing the credentials of every single person who files for a 99312 CPT code. What the payors actually require is that the pt has an indication and one placed the probe, performed the exam, acquired images, and filed a written exam interpretation. The ability to perform TEE and the level CPT code at which it's billed is usually controlled at the hospital administration level when you are initially privileged.

That being said, I'd recommend any critical care fellow to take the CCEeXAM and become certified, or if your program has enough elective time for TEE and you plan to have primarily CTICU as your practice, try to get the numbers to get advanced PTE certified. I suspect that going forward, more and more hospitals are going to put restrictions on who can and can't use the following ultrasound codes:

SCCM | Ultrasonography in Critical Care

Learn about billing and coding for ultrasonography in critical care.

www.sccm.org

Please see the highlighted portion (page 7) of the attached Novitas TEE LCD. Physicians in 12 states must be NBE certified in order to bill Medicare for TEE.

 

[vector2]

Please see the highlighted portion (page 7) of the attached Novitas TEE LCD. Physicians in 12 states must be NBE certified in order to bill Medicare for TEE.

Here's the full language from the section for people who don't open the pdf:

"​

Provider Qualifications​

​

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 post payment 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 post payment audit. A physician or a sonographer may personally perform cardiac ultrasound procedures. When a physician employs auxiliary personnel to assist him /her in providing ultrasound procedures, the services of such personnel are considered ‘incident to’ to the physicians’ services. All guidelines set forth by CMS regarding ‘incident to’ must be met.​

​

Cardiovascular Disease/Cardiology, Cardiovascular Surgery, Anesthesia, Critical Care Medicine, and Pediatric Cardiologists are thought to have the formal training or clinical training to do these tests. Other specialties may see denials for these services. For all specialties, certification by the National Board of Echocardiography will be essential in allowing coverage for services and can be submitted in the appeals process should a denial occur."​

LCD - Transesophageal Echocardiography (TEE) (L35016)

Use this page to view details for the Local Coverage Determination for Transesophageal Echocardiography (TEE).

www.cms.gov

​

It's kind of strange language where, indeed, it does sound like certification would be necessary "in allowing coverage for services," but on the other hand they make mention that folks like those trained in CCM or CV surgery have the training to do these tests.... but CV surgeons and intensivists (until recently with the CCEeXAM) never take the NBE exams, let alone become certified.

I will say that I know a few other people who are cardiac anesthesiology fellowship trained from the 2000s or 2010s but who never finished their certifying process for the NBE, and the TEE billing issue has never come up even though they're testamurs in the directory. One of the cardiologists here at my hospital who performs and reads both TTE and TEE is only a testamur of the ASCeXAM. And I live in one of the 12 states listed in the LCD and I can show you my collections for 93312 TEEs for the last few years.

Additionally, if one looks at the Intersocietal Accreditation Commission Standards & Guidelines for Echocardiography Accreditation (which any echo lab worth its salt has IAC) located here https://intersocietal.org/wp-content/uploads/2021/07/IACAdultEchocardiographyStandards2021.pdf , you'll notice that:

There is no mention of NBE certification for medical staff. Furthermore, if you scroll up from that page you'll see that there's not even an NBE certification requirement for the medical director of the echo lab.

All in all, I think the mention of certification in the LCD is mostly present to address situations where fraud or inappropriate billing is noticed through an audit, and in that case a person or facility would use certification in the appeals process to show appropriateness of the procedure/billing etc.

 

[deleted87051]

Here's the full language from the section for people who don't open the pdf:

"​

Provider Qualifications​

​

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 post payment 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 post payment audit. A physician or a sonographer may personally perform cardiac ultrasound procedures. When a physician employs auxiliary personnel to assist him /her in providing ultrasound procedures, the services of such personnel are considered ‘incident to’ to the physicians’ services. All guidelines set forth by CMS regarding ‘incident to’ must be met.​

​

Cardiovascular Disease/Cardiology, Cardiovascular Surgery, Anesthesia, Critical Care Medicine, and Pediatric Cardiologists are thought to have the formal training or clinical training to do these tests. Other specialties may see denials for these services. For all specialties, certification by the National Board of Echocardiography will be essential in allowing coverage for services and can be submitted in the appeals process should a denial occur."​

LCD - Transesophageal Echocardiography (TEE) (L35016)

Use this page to view details for the Local Coverage Determination for Transesophageal Echocardiography (TEE).

www.cms.gov

​

It's kind of strange language where, indeed, it does sound like certification would be necessary "in allowing coverage for services," but on the other hand they make mention that folks like those trained in CCM or CV surgery have the training to do these tests.... but CV surgeons and intensivists (until recently with the CCEeXAM) never take the NBE exams, let alone become certified.

I will say that I know a few other people who are cardiac anesthesiology fellowship trained from the 2000s or 2010s but who never finished their certifying process for the NBE, and the TEE billing issue has never come up even though they're testamurs in the directory. One of the cardiologists here at my hospital who performs and reads both TTE and TEE is only a testamur of the ASCeXAM. And I live in one of the 12 states listed in the LCD and I can show you my collections for 93312 TEEs for the last few years.

Additionally, if one looks at the Intersocietal Accreditation Commission Standards & Guidelines for Echocardiography Accreditation (which any echo lab worth its salt has IAC) located here https://intersocietal.org/wp-content/uploads/2021/07/IACAdultEchocardiographyStandards2021.pdf , you'll notice that:

View attachment 354561

There is no mention of NBE certification for medical staff. Furthermore, if you scroll up from that page you'll see that there's not even an NBE certification requirement for the medical director of the echo lab.

All in all, I think the mention of certification in the LCD is mostly present to address situations where fraud or inappropriate billing is noticed through an audit, and in that case a person or facility would use certification in the appeals process to show appropriateness of the procedure/billing etc.

That’s correct. The director of our echo lab is a board certified cardiologist, reads hundreds (maybe thousands) of echos every year, published widely in POCUS and echo, but does not have any NBE certification. In fact, in his role as the director of our echo lab, he signed off for one of my former partners who needed supervised exams to get NBE certification through the practice experience pathway when that was still available.

 

[PpfSuxTube]

I find this topic interesting. I dont think i would want the responsibility of having to make a sometimes life altering call based on a basic course without fellowship. But different sttokes for different folks...

Yesterday 4 of us spent probably 30 mins deliberating a study and what to do next in a decompenating patient. Probably 10000 studies between us, maybe more

Ive seen some really just wrong calls made over the years. Oh well...

 

[Hork Bajir]

I find this topic interesting. I dont think i would want the responsibility of having to make a sometimes life altering call based on a basic course without fellowship. But different sttokes for different folks...

Yesterday 4 of us spent probably 30 mins deliberating a study and what to do next in a decompenating patient. Probably 10000 studies between us, maybe more

Ive seen some really just wrong calls made over the years. Oh well...

Do us (me) a favor and post that case in my favorite thread, “let’s do some echo” : )

Let's do some echo:

Embolized IAS occluder device? Wow, strong work! It’s an amplatzer septal occlusion device that embolized after attempted deployment. Unable to retrieve in cath lab, came emergently to OR for open retrieval.

forums.studentdoctor.net

 

[vector2]

make a sometimes life altering call based on a basic course

I don't think anyone is advocating this.

 

[POW16]

For those of you who advocate taking the basic exam, how do you keep up your skills ? Don't you need a certain number of exams/year ? Do you do several liver transplants every week ? Do you drop a probe in anytime an ICU patient is on more than one pressor ? I find TTE (POCUS) is usually adequate for the latter.

 

[sevoflurane]

I don't think anyone is advocating this.

exactly.

I recently had a grossly mismanaged patient come to the OR from the ICU. On pressors, combined metabollic/respiratory acidoses, glucose in the 300’s, base deficit of -14 despite 2-3 liters in the OR.

Turned out to be right mainstream, but that didn’t explain everything. Dropped a probe shortly after pulling the tube back and despite the 2-3 liters pap muscles were kissing. No guessing on what to do thereafter. Easy dx and any anesthesia doc with basic tee knowledge could have done the same.

 

[sevoflurane]

Honestly hope residencies get their act together and train all of their residents on basic tee. Even basic TEE skills (like regional anesthesia) can distinguish us as advanced medical practitioners… which we are.

 

[sevoflurane]

You can make the argument for urine output, respiratory variation on an a-line, response to fluid volume, etc….. None of those modalities are near as cut and dry as a quick echo… and you often gather a lot more information that may help your management (rwma, valvular disease, EF, etc)

 

[sanityonleave]

For those of you who advocate taking the basic exam, how do you keep up your skills ? Don't you need a certain number of exams/year ? Do you do several liver transplants every week ? Do you drop a probe in anytime an ICU patient is on more than one pressor ? I find TTE (POCUS) is usually adequate for the latter.

I average ~2-3 exams/month between liver transplants, TAAAs, renal cell CA w/ IVC thrombus, etc.

I definitely am not an echo wiz by any stretch, especially compared to the full time CV guys on here (though the TEE thread is great fun), but it's helpful for big stuff that I'm care about. Massive PE, severe valvular disease, bad failure - things that are going to make it hard for me to successfully get a patient through the case and off the table.

We also have a CV anes trained provider in the CVICU basically 24/7, so if I see something I don't understand or I'm not sure about I call for a second set of eyes (either from the OR or from the ICU if it's the middle of the night).

I think you're right to wonder about staying sharp, but as long as you have humility about your skill set (i.e. don't overestimate your own ability to rule in or out pathology) it can be a great tool.

 

[Hork Bajir]

despite the 2-3 liters pap muscles were kissing

In fairness, “kissing paps” (low LVESV) can be seen for a number of reasons: low LV preload as a result of hypovolemia or increased venous compliance, low LV preload as a result of RV failure, or low afterload in the setting of vasodilatory shock, liver failure, etc. more fluid is not the treatment of choice for every case of end-systolic cavity obliteration… Of course you can sort all of these diagnoses out using TEE as well, in a matter of seconds: measure LV end diastolic diameter, assess IVS position, check LVOT VTI, etc.

As a cardiac doc @sevoflurane obviously knows all of this stuff inside and out, but I feel it’s important to state explicitly for any trainees reading this thread. I’ve lost count of the number of residents who look at an echo showing good diastolic filling with a hyperdynamic heart and immediately tell me “KISSING PAPS, THEY MUST BE DRY”… When the correct answer is actually to restore afterload

 

[sevoflurane]

^ agree 100%
This particular case was dropped off euvolimic after multiple units and liters of fluids.
Base excess of +1. Glucose 130’s. Off of pressors. Normalized ph.
Can’t remember the rest, but basically tuned up from a major misunderstanding of the patients status.
It’s really the analogy of stimulator vs usd driven PNB care. One is vastly superior and just tells you so much more.

 

[sevoflurane]

In practice, I feel like TEE is an underused, low risk tool that just makes your life and the understanding of your patients pathology better… be it in the cardiac room, trauma room, ex-lap/septic disaster or even in the rare instances like OB practice. As a specialty, we are in the right perioperative space to own it and I think we should.

 

[shepardsun]

glad to see this thread as a generalist working on basic certification right now just because sometimes I feel dumb in a crisis and wish I could be less dumb by getting a better picture of what's actually going on with the pump