Echocardiography, Transthoracic Targeted Probe and Educate Review Results - JE Part A
Echocardiography, Transthoracic Targeted Probe and Educate Review Results
The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Current Procedural Terminology (CPT®) code 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 quarterly edit effectiveness results from January 1, 2024 through March 31, 2024 are as follows:
Top Denial Reasons
- Medical Necessity for Transthoracic Echocardiographs
- Documentation Supporting Services Rendered
Educational Resources
- Documentation Requirements - JF Part A - Noridian (noridianmedicare.com)
- National Coverage Determination (NCD): NCD - Ultrasound Diagnostic Procedures (220.5) (cms.gov)
- IOM, Publication 100-02, Medicare Benefit Police Manual (MBPM), Chapter 15, Section 80
- IOM, Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3
Education
Medical Necessity for Transthoracic Echocardiographs
National Coverage Determination (NCD) 220.5 Ultrasound Diagnostic Procedures lists echocardiography as a category I procedure and it is not considered experimental. Per the Social Security Act 1862 (a)(1)(A) a service must be "reasonable and necessary for the diagnosis and treatment of an illness or injury or to improve the functioning of a malformed body member."
In determining if a transthoracic echocardiograph provided was reasonable and necessary, review of guidelines from national specialty societies assist to establish an accepted standard of medical practice. For example, the American College of Cardiology (ACC) and the American Heart Association (AHA) provide practice guidelines for echocardiography in the ACC/AHA Guidelines for the Clinical Application of Echocardiography. The guidelines assist physicians in clinical decision making and attempt to establish practice guidelines for most patients in most circumstances.
Additional guidelines and Appropriate Use Criteria may be found on the American College of Cardiology website.
Documentation Supporting Services Rendered
Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."
No Medicare payment can be paid for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service was not rendered. Services will be denied without the necessary documentation to support services were rendered as billed.
