VAE and TEE

[DreamLover]

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So what is your favorite TEE view to best monitor for VAE?

Midesoph RV inflow outflow?

What is your choice of monitor? Precordial Vs TEE

Does anyone/Has anyone ever monitored ET Nitrogen successfully?
- I've never had monitors capable of this so I've never even tried

I'm just curious about current opinion/practice

 

[proman]

I've only used precordial doppler. It's painless to use and allows the surgeon to also be aware.

I think any of the right heart views would work. The RV outflow/PA view seems to be popular in the literature. The RV inflow/outflow view provides a limited amount of RV to assess for function. I'd probably pick the 4 chamber view since it would also show LV function/air at the same time. The most sensitive view is probably bicaval or modified bicaval view. That view would also allow you to locate the source (IVC vs SVC vs coronary sinus). Downside is having no view of the ventricles (but you would get left atrium). TEE picks up such a miniscule amount of air that it would probably have you on edge the whole case (like precordial doppler). Never used EtN2 (except on the orals, of course).

 

[B-Bone]

In reality, TEE isn't a great monitor of air because it requires you to keep the probe on at all times and also requires someone to be staring at the TEE all the time. If using it as your sole monitor of air, the probe can get hot if left on continuously and not moved. If combining it with PCD, it will make a really annoying whine when the probe is on and lots of noise (that can sound like air) with probe manip. In residency I used to practice doing full TEE exams on neuro pts during long boring sitting cranis or neck cases. The first time I did this with a PCD in place, the PCD made all kinds of racket when I turned on the probe and manipulated it. The surgeon assumed any noise from the doppler meant massive air and proceeded to lose his s%^t. yay for learning. Subsequently I learned to turn the doppler off (or at least volume down) before mucking around with the TEE.
It works great as confirmation of air and to get an idea of how much is in there, but for real time monitoring I find it overkill and frankly a bit annoying.

 

[Bertelman]

In reality, TEE isn't a great monitor of air because it requires you to keep the probe on at all times and also requires someone to be staring at the TEE all the time. If using it as your sole monitor of air, the probe can get hot if left on continuously and not moved. If combining it with PCD, it will make a really annoying whine when the probe is on and lots of noise (that can sound like air) with probe manip. In residency I used to practice doing full TEE exams on neuro pts during long boring sitting cranis or neck cases. The first time I did this with a PCD in place, the PCD made all kinds of racket when I turned on the probe and manipulated it. The surgeon assumed any noise from the doppler meant massive air and proceeded to lose his s%^t. yay for learning. Subsequently I learned to turn the doppler off (or at least volume down) before mucking around with the TEE.
It works great as confirmation of air and to get an idea of how much is in there, but for real time monitoring I find it overkill and frankly a bit annoying.

Why exactly did these Pt's have a TEE probe inserted for these cases? Was it solely to monitor for VAE?

 

[B-Bone]

Why exactly did these Pt's have a TEE probe inserted for these cases? Was it solely to monitor for VAE?

The real answer is because it was a training program. At our shop, the sitting cases (cranis, c-spines, suboccipital decompressions) got art line, doppler, TEE, and long arm CVP. This was basically ordained by the principle of "maximal resident benefit" in order to teach us how to do all this. Our attendings would claim the TEE was for air detection and to look for PFO's (although what we were supposed to do different when we found one was exactly nothing). They all admitted that if they were doing these cases on their own or in the real world it'd be art line +/- doppler. I guess that's what residency's for, though, right? Great learning experience for me, though I haven't done a sitting neuro case since I left training.

 

[Bertelman]

The real answer is because it was a training program. At our shop, the sitting cases (cranis, c-spines, suboccipital decompressions) got art line, doppler, TEE, and long arm CVP. This was basically ordained by the principle of "maximal resident benefit" in order to teach us how to do all this. Our attendings would claim the TEE was for air detection and to look for PFO's (although what we were supposed to do different when we found one was exactly nothing). They all admitted that if they were doing these cases on their own or in the real world it'd be art line +/- doppler. I guess that's what residency's for, though, right? Great learning experience for me, though I haven't done a sitting neuro case since I left training.

Great experience for you, though it's not exactly a benign procedure. You think that is still occurring at your institution? Not sure when this was occurring, but were patients consented for TEE insertion? Risks discussed?

 

[B-Bone]

Great experience for you, though it's not exactly a benign procedure. You think that is still occurring at your institution? Not sure when this was occurring, but were patients consented for TEE insertion? Risks discussed?

definitely still going on. we always consented for TEE and didn't use it on folks with contraindications (e.g. coagulopathy, strictures, esoph/GE junction surgery, etc). R/B/A discussed. I don't think it's the standard of care obviously, but certainly not unreasonable or even that uncommon in sitting neuro cases. The textbooks all discuss TEE for this.

My program's philosophy (like a lot of teaching institutions) on this was that if monitors/lines/blocks/etc were reasonable for the pt/case (if not completely "necessary") they would usually be done. Matching for case/pt complexity, I placed way more invasive lines/monitors in residency than I do now in PP, but never anything that was unreasonable for the situation.

 

[nimbus]

My program's philosophy (like a lot of teaching institutions) on this was that if monitors/lines/blocks/etc were reasonable for the pt/case (if not completely "necessary") they would usually be done. Matching for case/pt complexity, I placed way more invasive lines/monitors in residency than I do now in PP, but never anything that was unreasonable for the situation.

Don't kid yourself. All those lines/blocks/moniters are not only for maximal resident benefit but also for maximum departmental revenue and attending bonuses.

 

[periopdoc]

Barring some miraculously good relationship between the billing folks and the insurance companies they work with, they are not getting paid for the TEE portion.

- pod

 

[sevoflurane]

Barring some miraculously good relationship between the billing folks and the insurance companies they work with, they are not getting paid for the TEE portion.

- pod

During a routine CABG that has a pre-op echo are you getting paid for:

TEE Insertion
TEE Monitoring
TEE Diagnostics/Color Flow/Epiaortic Scanning/etc.?

We have a new biller and it is her understanding that medicare doesn't pay for this. Do you need to pick up a new diagnosis in order to get paid? I've been looking into this lately.

What is your billing practice like in this scenario?

 

[sevoflurane]

Or placement of an IABP at the end of a difficult case?

 

[periopdoc]

During a routine CABG that has a pre-op echo are you getting paid for:

TEE Insertion
TEE Monitoring
TEE Diagnostics/Color Flow/Epiaortic Scanning/etc.?

We have a new biller and it is her understanding that medicare doesn't pay for this. Do you need to pick up a new diagnosis in order to get paid? I've been looking into this lately.

What is your billing practice like in this scenario?

Nope
Nope
and Nope

Your biller is correct.

Unless there is a billable indication I don't place the probe. This may present a problem if we need to place a balloon intraop, but usually we can predict the need and place the balloon pre-emptively before we start operating.

- pod

 

[B-Bone]

During a routine CABG that has a pre-op echo are you getting paid for:

TEE Insertion
TEE Monitoring
TEE Diagnostics/Color Flow/Epiaortic Scanning/etc.?

We have a new biller and it is her understanding that medicare doesn't pay for this. Do you need to pick up a new diagnosis in order to get paid? I've been looking into this lately.

What is your billing practice like in this scenario?

Not sure what medicare has to say on the issue, but the ASA practice guidelines on periop TEE say the following:

-should be used on all adult open heart (i.e. valve) and thoracic aortic cases (in pt's without contraindications) and should be considered on CABG cases.
-may be used in transcatheter intracardiac cases
-may be used in non-cardiac surgery when
a. the nature of the planned surgery or the patient's known or suspected cardiac pathology might result in severe hemodynamic, pulmonary,or neurologic compromise
b. unexplained life-threatening circulatory compromise persists despite corrective therapy

Seems like the ASA thinks CABG should definitely be considered an indication, and given the pretty broad verbage in a and b above, they're leaving it pretty wide open to use TEE as monitor when you feel it is necessary/helpful.

Of course, this is just the ASA and not the people footing the bill.

CMS says you can't bill for TEE as a routine monitor (it even says it in BOLD!). Their rules seem to say that TEE must be indicated as a diagnostic test to be billable. They do have codes for TEE during non-cardiac surgery, but note that if these codes are used, the anesthesia records must be made available to CMS (presumably so they can decide whether TEE was indicated).

Here are some links!

http://www.cms.gov/medicare-coverage-database/lcd_attachments/28574_21/L28574_CV007_CBG_110110.pdf

http://www.asahq.org/publicationsAndServices/practiceparam.htm

 

[periopdoc]

I appreciate the stances taken by ASA/ ASE/ and SCA and will use them to defend my billing practices if I am ever challenged. (CMS has verbiage regarding billing for non-indicated procedures as if they were indicated which makes me nervous about the potential for an audit if I get caught billing for TEE used in "non-indicated" procedures) However, when it comes down to it, the only thing that really matters is what CMS says. I find the guidelines to be pretty vague and open to interpretation which is why the carrier interpretations are a little more enlightening on what is and isn't legitimately billable.

Trailblazer health has some easy to search guidelines/ interpretations and has this to say about TEE.

Interventional and Surgical TEE: TEE can be of utility during percutaneous and surgical cardiac interventions. In selected instances, TEE can provide guidance during the creation of shunts, placement of septation devices, performance of valvular plastic procedures and replacement when the surgical result cannot be adequately assessed by other means. In lung or heart-lung transplant, the integrity and morphology of pulmonary vascular anastomoses is critical. Intraoperative TEE can assist in surgical management decisions.

Intraoperative TEE monitoring of ventricular function in selected high-risk patients can complement hemodynamic monitoring data. Assessment for changes in volume and of global and regional myocardial contractility can be therapeutically useful. Routine application, even in patients undergoing cardiopulmonary bypass and valvular surgeries, cannot be supported. (emphasis added) Prior to elective percutaneous mitral valvuloplasty, TEE is used to assess for left atrial thrombi.

Medicare payment for the professional component of intraoperative TEE is justified for instances in which intraoperative echocardiography is an adjunct to optimal performance of a surgical procedure or for a specific diagnostic reason (e.g., proper valve placement, guiding of the placement of a device to close an atrial septal defect, evaluation of mitral balloon valvuloplasty, etc.). Intraoperative echocardiographic services must include a complete interpretation and written report by the performing physician, and images obtained must be stored in the same manner as other echocardiographic services to warrant separate payment.

I have not seen a good definition of "selected high-risk patients" in which TEE would be billable during otherwise "non-indicated" procedures. In cases that I deem to meet these criteria I include a statement in my report on why the patient is high-risk and that TEE was used to assess patient volume status and contractility and make real-time adjustment of volume and inotropic support.

Don't forget, the original question from Sevo had the following qualifier...

During a routine CABG that has a pre-op echo

- pod

 

[sevoflurane]

Thanks for the link POD.

I have not seen a good definition of "selected high-risk patients" in which TEE would be billable during otherwise "non-indicated" procedures.
- pod

CABG with EF <35% vs EF>35%? I've heard this but can't validate it via anything I've read.

 

[proman]

Thanks for the link POD.
CABG with EF <35% vs EF>35%? I've heard this but can't validate it via anything I've read.

I don't really care what the insurance will reimburse. TEE for CABG is not a Category 1 indication but I will do it on all patients without contraindication. Case in point: I was scheduled for a robotic CABG recently. Preop chest wall echo report was "normal mitral leaflets, mild regurgitation". My preop TEE exam showed P2 posterior leaflet prolapse, severe eccentric regurgitation with systolic blunting of the RUPV. Discussed with the surgeon, who spoke with the family and we all agreed an open MV repair and CABG would be more appropriate. The patient did well and was very appreciative. When I reviewed the preop TTE loops, the P2 prolapse was evident as was the MR. Had I not done an exam because it was only a CABG we wouldn't have done the right thing for the patient.

 

[sevoflurane]

I don't know if I've ever done a heart without TEE. Getting paid for it is another story.

 

[sevoflurane]

Case in point: I was scheduled for a robotic CABG recently. Preop chest wall echo report was "normal mitral leaflets, mild regurgitation". My preop TEE exam showed P2 posterior leaflet prolapse, severe eccentric regurgitation with systolic blunting of the RUPV. Discussed with the surgeon, who spoke with the family and we all agreed an open MV repair and CABG would be more appropriate. The patient did well and was very appreciative. When I reviewed the preop TTE loops, the P2 prolapse was evident as was the MR. Had I not done an exam because it was only a CABG we wouldn't have done the right thing for the patient.

Good work. 👍

 

[periopdoc]

In residency/ fellowship and now in practice we frequently did/ do CABG without TEE.

Since you found mitral valve pathology, you can bill for that echo. It is almost a catch-22... you don't always know whether there is a class 1 indication unless you stick the probe in and find out.

It is always a good idea to review the preop TTE yourself prior to the surgery when possible. (not being critical as I frequently do not take the opportunity to do this myself)

- pod

 

[proman]

In residency/ fellowship and now in practice we frequently did/ do CABG without TEE.

Since you found mitral valve pathology, you can bill for that echo. It is almost a catch-22... you don't always know whether there is a class 1 indication unless you stick the probe in and find out.

It is always a good idea to review the preop TTE yourself prior to the surgery when possible. (not being critical as I frequently do not take the opportunity to do this myself)

- pod

I don't disagree. At a minimum I always look at the report. But when I've looked at the TTEs on suspicious reports, I've found a number of errors, either poor exams or incorrect interpretation. The problem is that the cardiology archival system is separate, I can't access it over the wireless network (I use my MacBook Air at work) and not all computers in the workroom can run it.

You can bill for TEE for CABG if there's aortic atherosclerosis, and I'd say that nearly 100% of CAD patients have at least intimal thickening 😉.

 

[periopdoc]

Unfortunately, the reality of it is that cardiac anesthesia fellows get significantly more echo training than the general cardiologist and it isn't uncommon to find errors. Fortunately, I have been blessed with cardiologists who are good at reading echos and sonographers who are good at obtaining the appropriate images. I too struggle with the issue of proprietary software and getting into the reading room to look at the echo beforehand. It would be sweet if I could view the images from my MBA at home.

I always find a reason to get paid when I do TEE. At the very least, I make some suggestions to the surgeon about optimal cannulation sites given the underlying aortic disease. However, if we are ever audited, it will be a bit easier for me to argue that I only use it for "selected high-risk" patients since I don't use it ubiquitously.

- pod

 

[IN2B8R]

I don't really care what the insurance will reimburse. TEE for CABG is not a Category 1 indication but I will do it on all patients without contraindication. Case in point: I was scheduled for a robotic CABG recently. Preop chest wall echo report was "normal mitral leaflets, mild regurgitation". My preop TEE exam showed P2 posterior leaflet prolapse, severe eccentric regurgitation with systolic blunting of the RUPV. Discussed with the surgeon, who spoke with the family and we all agreed an open MV repair and CABG would be more appropriate. The patient did well and was very appreciative. When I reviewed the preop TTE loops, the P2 prolapse was evident as was the MR. Had I not done an exam because it was only a CABG we wouldn't have done the right thing for the patient.

Well, a TEE will definitely pick up mitral valve pathology much better than a TTE. Why they missed severe MR on a pre-op surface echo (in a patient who more than likely had some symptoms of severe MR....) is another story....

 

[sevoflurane]

Case from last week:

Routine CABG with preserved LV funciton. You are peeling around the descending aorta SAX and see a severely calcified vascular tube with a calcified spermling that took the wrong turn when traveling through the fellopian tubes.

Descending aorta not mentioned in the pre-op echo.

Would any of you bill for this echo?

 

[proman]

You can bill for this (and the epiaortic exam that should follow). Was the goober mobile? That's Grade V disease.

 

[proman]

Unfortunately, the reality of it is that cardiac anesthesia fellows get significantly more echo training than the general cardiologist and it isn't uncommon to find errors. Fortunately, I have been blessed with cardiologists who are good at reading echos and sonographers who are good at obtaining the appropriate images. I too struggle with the issue of proprietary software and getting into the reading room to look at the echo beforehand. It would be sweet if I could view the images from my MBA at home.

Ironically I can see them from home or my office (I do have to use my Parallels/Windows setup since the hospital intranet doesn't work on Macs). Even good cardiologists will miss things (just like we miss things).

Well, a TEE will definitely pick up mitral valve pathology much better than a TTE. Why they missed severe MR on a pre-op surface echo (in a patient who more than likely had some symptoms of severe MR....) is another story....

Without question TEE is superior. The MR was subtle on TTE because of a eccentric jet that was directed toward the IA septum then curled posterior right into the right pulmonary veins. The standard measurements (like vena contracta, regurgitant volume or fraction) underestimates these kinds of jets. The patient was fairly well compensated but had a diagnosis of "pulmonary fibrosis" which I think was likely from the MR.

 

[sevoflurane]

You can bill for this (and the epiaortic exam that should follow). Was the goober mobile? That's Grade V disease.

Suprisingly... no, despite a thin neck. Give it time... it'll go somewhere some day. I find this type of data helpful if said patient were to wake up with a cold foot, dysarthria, etc.

My partner picked up a perivalvular leak after a mitral valve replacement 2 weeks ago. Definitely can bill for that.

Would you guys bill for TEE on all valves.? Insertion of coronary sinus catheter with TEE guidence, detection of intracardiac air, approximation of valve size. These are not "new diagnoses" (except for maybe intracardiac air).

Appreciate the comments. 🙂

 

[sevoflurane]

You can bill for this (and the epiaortic exam that should follow). Was the goober mobile? That's Grade V disease.

He already has a diagnosis of atherosclerosis and PVD...😕

 

[Bertelman]

Suprisingly... no, despite a thin neck. Give it time... it'll go somewhere some day. I find this type of data helpful if said patient were to wake up with a cold foot, dysarthria, etc.

My partner picked up a perivalvular leak after a mitral valve replacement 2 weeks ago. Definitely can bill for that.

Would you guys bill for TEE on all valves.? Insertion of coronary sinus catheter with TEE guidence, detection of intracardiac air, approximation of valve size. These are not "new diagnoses" (except for maybe intracardiac air).

Appreciate the comments. 🙂

I think you should be able to bill on any valve replacement, and repair as well, if you follow POD's post above. I would consider post-procedure assessment of valvular fx an "adjunct to optimal performance".

In the current climate of reimbursements, though, I wouldn't exactly hold my breath for this to happen. But then again, I know very little about billing, having never submitted one myself.

"Medicare payment for the professional component of intraoperative TEE is justified for instances in which intraoperative echocardiography is an adjunct to optimal performance of a surgical procedure or for a specific diagnostic reason (e.g., proper valve placement, guiding of the placement of a device to close an atrial septal defect, evaluation of mitral balloon valvuloplasty, etc.). Intraoperative echocardiographic services must include a complete interpretation and written report by the performing physician, and images obtained must be stored in the same manner as other echocardiographic services to warrant separate payment."

 

[sevoflurane]

I would consider post-procedure assessment of valvular fx an "adjunct to optimal performance".

Me too but as pod pointed out this may be subject to interpretation.... 🙄 .

This is one aspect of training I wish residencies would improve on. Billing and coding is an integral part to any practice. It also can be challenging, often taking 4-8% of practice revenues. Over-billing AND under-billing can cause a RAC audit as per my understanding. Fortunately for me, I don't have to worry about it. Our billers/coders (actually our hospitals billers and coders) handle this aspect of our practice and do a great job.... I think...?

Recently I have been interested in our collections and have pointed out a couple areas that could be improved upon. Suffice it to say, I just do my TEE exam and the rest is out of my hands.... but it's good to know what is being billed and what is not. What is being collected and what is not (and why not) is equally important, IMO.

Pretty dry subject and not a lot of physiology in this aspect of practice. Very useful, especially if one is forced to code all their cases (many groups function like this).

Here is a quick read for those senior residents getting ready to hit private practice. You likely won't get this in residency:

http://www.orionhealthcorp.com/LinkClick.aspx?fileticket=A9lAk2Zkb5M=&tabid=121

 

[periopdoc]

I should note that I vehemently disagree with the interpretation that routine application for valvular surgery cannot be supported. I just wanted to let you know what is out there. I do not believe that my carrier has the same interpretation.

I follow the ASA/SCA Practice Guidelines for Perioperative Transesophageal Echocardiography.

1. Recommendations for cardiac and thoracic aortic surgery. For adult patients without contraindications, TEE should be used in all open heart (e.g., valvular procedures) and thoracic aortic surgical procedures and should be considered in coronary artery bypass graft surgeries to: (1) confirm and refine the preoperative diagnosis, (2) detect new or unsuspected pathology, (3) adjust the anesthetic and surgical plan accordingly, and (4) assess the results of surgical intervention.
2. Recommendations for catheter-based intracardiac procedures. For patients undergoing transcatheter intracardiac procedures, TEE may be used.
3. Recommendations for noncardiac surgery. TEE may be used when the nature of the planned surgery or the patient’s known or suspected cardiovascular pathology might result in severe hemodynamic, pulmonary, or neurologic compromise. If equipment and expertise are available, TEE should be used when unexplained life-threatening circulatory instability persists despite corrective therapy.
4. Recommendations for critical care. For critical care patients, TEE should be used when diagnostic information that is expected to alter management cannot be obtained by trans-thoracic echocardiography or other modalities in a timely manner.

I perform TEE for all procedures where a cardiac chamber is opened (valves, PFO repair, etc). I document that I evaluated the adequacy of the repair prior to decannulation and I used the TEE to guide our de-airing procedures and timing. I try to look at all four valves post-op to make sure that no leaflet was inadvertently stitched open. In my interpretation, you don't have to find a perivalvular leak to bill for the TEE, you just have to document looking for one.

The only cases where I don't routinely utilize TEE is straight forward CABGs even though I don't understand why it is ok to bill when "the patient’s known or suspected cardiovascular pathology might result in severe hemodynamic, pulmonary, or neurologic compromise." for non-cardiac surgery, but not for CABGs where that statement clearly applies to every patient operated on.

The thing we have to avoid is the determination that TEE is routine/ standard of care for these procedures. As soon as that happens, CMS will have the support for their argument that TEE is just a routine monitor and is included in the base units. I truly don't understand why CMS has such a hard on about TEE, but they do. There are other things which pay more, have less utility, and have been proven to be less helpful or perhaps even harmful that CMS has no issue with paying on. Then again, since when did logic have anything to do with CMS mandates?

- pod

 

[periopdoc]

He already has a diagnosis of atherosclerosis and PVD...😕

I thought you were joking about can you bill for this. Absolutely. I would document that after finding grade V disease in the descending aorta, I evaluated the ascending and transverse aorta and and advised the surgeon about potential sites for cannulation. (In reality I tell the surgeon there is significant atheromatous disease in the descending, but as far as I can tell the ascending and arch look ok or they look bad. I don't get too specific) Then I would bill for it.

- pod

 

[periopdoc]

This is one aspect of training I wish residencies would improve on. Billing and coding is an integral part to any practice. It also can be challenging, often taking 4-8% of practice revenues. Over-billing AND under-billing can cause a RAC audit as per my understanding.

Unfortunately, in general, academic attendings have no f'n clue about successful billing. I asked extensively about the subject during training and got mostly shrugs. The exception were the couple of guys who had been in private practice for several years before semi-retiring into academic practice.

At UW this was not helped by the billing system we utilized. During my fellowship we found out that our billers hadn't been submitting bills for our TEE's for quite some time.

Here is a quick read for those senior residents getting ready to hit private practice. You likely won't get this in residency:

http://www.orionhealthcorp.com/LinkClick.aspx?fileticket=A9lAk2Zkb5M=&tabid=121

Great link

- pod

 

[sevoflurane]

I should note that I vehemently disagree with the interpretation that routine application for valvular surgery cannot be supported.....

Then again, since when did logic have anything to do with CMS mandates?

- pod

👍

 

[sevoflurane]

I thought you were joking about can you bill for this.
- pod

Remember this was a routine CABG with preserved LV function. A lot of people, perhaps even yourself, wouldn’t have placed the probe in the first place + I don’t know if a diagnosis of atherosclerosis includes aortic atherosclerosis. I admit that if you are doing an epiaortic scan, then you should bill for it. This thread has made it obvious to me that there is a grey area when it comes to TEE billing. Some cases are clear cut, some are not. Goes back to proper documentation.

I’m going to have to look at what our coders/billers are doing cuz I get the feeling we are missing some billable TEE’s. It’s not a huge issue as we get a flat fee for each and every heart we bring into the OR (negotiated with our hospital). But when it comes down to renegotiating a contract you want to show what your group has collected year to year. Capturing procedures such as TEE’s, multiple regional blocks on the same patient, post-op visits, extreme age, field avoidance, unusual position, hypothermia etc... eventually makes a monetary difference. Not only are you providing a service but it becomes a bargaining chip for your group when it’s time to put ink to paper.

It’s always nice to double check with other providers and their billing habits. This thread has been very helpful. Thanks to pod, proman, b-bones, et al.

 

[periopdoc]

You are absolutely right. I would not have placed the probe in the first place. However, it gets back to my statement about always getting paid for the TEE's I do perform. I would have looked for (and found) something like this to justify billing for the exam.

It doesn't matter if severe aortic atherosclerosis was a pre-existing diagnosis or not. It is there and so you may bill for it. Just because we already know that there is aortic atherosclerosis doesn't mean we can't confirm the severity and alter (or not) the surgical approach based on our findings.

- pod

 

[Bertelman]

Bottom line for me: if you are accepting liability for a procedure, you should make an effort to bill for it.

 

[proman]

I don't have much more to add the what POD's posted about use. Like him, I follow the ASA/SCA usage, which means that about 98% of my CABGs get TEE barring a contraindication. As we do more minimally invasive approaches, TEE guided placement of bypass cannula and other catheters is also very important.

As to how we bill, we don't bill for a comprehensive exam. Medicare frowns on repeated testing, so if the patient has had 1 complete TTE we don't bill for the second, but for a limited study instead. To get reimbursed for an otherwise completely normal CABG, you'll need some form of atherosclerotic disease. The aorta frequently has intimal thickening (Grade I disease) and/or the sinotubular junction is frequently calcified. It's amazing.