Refresher Course on TEE Documentation

    As you have seen in prior client alerts, billing for Transesophageal Echocardiography (TEE) requires very specific documentation in the medical record. Any gaps in this documentation may lead to reduced or lack of billing for services rendered – or inappropriate billing of services that should not be billed.  As such, requests to review TEE reports have increased substantially over the past year. This alert will outline and explain the critical elements you must document to bill for these services, and to reduce requests for additional information.


    1. What did you perform? 

    Placement, Interpretation, or Both?

    In order to accurately bill what you did, we must know what service you personally performed.


    1. What Was the Purpose?

    Diagnostic or intraoperative monitoring?

    Past alerts have delved into the definition of “diagnostic” from the payer’s standpoint. Ultimately, you as the clinician are responsible for ensuring your familiarity with these guidelines and appropriately designating the Transesophageal Echocardiography service as diagnostic vs. monitoring.  Note: No Transesophageal Echocardiography can be considered “diagnostic” without the presence of a formal interpretation report.  You do not have to personally perform the interpretation, but someone must, and the report must be retrievable from the medical record.


    1. Were any Modalities Performed?

    In many cases, the modalities used are only noted on the report, which may or may not be available to Medac. Pulsed wave / spectral display, and color flow velocity mapping are separately billable services in addition to the TEE.

    Accurate and consistent utilization of the 8 checkboxes below meets the minimum standard of what Medac needs from you to bill for TEE services.  Please note you are not required to use this format, but documenting the specific items below is the best way to communicate exactly what service you provided.  Also note you are still required to ensure these selections are accurate and any additional information to support these selections is included in the medical record.


    For more information, please read these two excellent alerts previously sent by Justin Vaughn (attached):


    If you have additional questions about documenting and/or billing for TEEs, please contact your Practice Manager or Compliance Officer.


    •  MEDAC – Committed to Continuing Client Education  •


    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.