Transesophageal Echocardiography (TEE)

LCD Information Document Information Source LCD ID N/A LCD ID L34337 Original ICD-9 LCD ID Not Applicable LCD Title Transesophageal Echocardiography (TEE) Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 09/04/2025 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations, and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(a)(7) of Title XVIII of the Social Security Act excludes routine physical examination, unless otherwise covered by statute.Code of Federal Regulations:42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) and the results must be used in the management of the patient. 42 CFR, Section 410.33c, describes qualifications required for non-physician practitioners used by an IDTF. CMS Publications:CMS Publication 100-02, Medicare Coverage Issues Manual, Chapter 15: 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9: 100 General Billing Requirements CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12: CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 13: 20 Payment conditions for radiology services National CCI Manual, version 13.3, Chapter II: CCI editing for anesthesia services; accessible at http://www.cms.hhs.gov/NationalCorrectCodInitEd/ Coverage Indications, Limitations, and/or Medical Necessity Abstract:Transesophageal echocardiography (TEE) is performed by placing the ultrasound transducer in the esophagus achieving closer proximity to the anatomical structures of the heart, and improved image quality. This is particularly useful for posterior structures, such as the pulmonary veins, left atrium, and mitral valve. It also provides better visualization of the aortic root, valve and the ascending and descending aorta and arch.The placement of the probe is relatively invasive, with risk of laryngeal or esophageal tears, and requires conscious sedation. TEE is performed by a physician echocardiographer trained to interpret the data on-line. TEE is frequently not medically necessary when a technically adequate TTE has been performed. If TTE is technically inadequate, or demonstrates pathology but does not provide adequate data for definitive therapeutic decision, TEE may be considered appropriate. Furthermore, there are a number of medical conditions for which TEE is preferred over transthoracic echocardiography. Medically necessary TEE is expected to provide information not available with TTE, and to significantly contribute to management decisions regarding treatment of the patient.This policy defines clinical pathophysiologic states for which this contractor will provide coverage for TEE examinations. Covered conditions reflect those for which there is authoritative literature to support clinical utilization. Indications:Doppler Color Flow Velocity Mapping: "Color/spectral Doppler may not be useful or appropriate in certain relatively small and well-defined patient populations when there is a recent comprehensive examination and the test is being ordered for re-evaluation of a limited problem." (ASE comment). The use of the Doppler is inherent in the ultrasonic cardiac evaluation. However, if the test reports fail to document the use of this technique to assess these structures and function (e.g., measurement of valvular insufficiency or stenosis, myocardial diastolic function, etc. as described by the ASE), or if the medical records fail to document that the examination was "clinically necessary" (e.g., follow-up of pericardial effusion size) then the Doppler portion of the test may be considered medically unnecessary and denied. Mitral valve disease:TEE is indicated for the following: When needed to assess the etiology of mitral regurgitation When needed to assist in the decision making: mitral valve repair vs. replacement Endocarditis: TEE is indicated for the following: When the suspicion of endocarditis is high (persistent febrile state, negative cultures, preexistent valvular pathology) and TTE does not document endocarditis. TEE may define small vegetative masses and more completely delineate local complications (e.g., ring abscesses, aneurysm, fistulae). Re-evaluation in complex endocarditis; Evaluation of bacteremia without known source; and Evaluation of suspected or actual prosthetic valve endocarditis otherwise obscured because of reverberations and other image artifacts related to mechanical or other non-native valves during TTE. Valvular Prostheses (mechanical and bioprostheses): TEE is indicated in the evaluation of suspected prosthetic valve dysfunction when therapeutic decisions are critical and TTE is inconclusive and/or when the left atrium must be well-visualized. TEE is not routinely indicated in all patients with prosthetic valves. Suspected Cardiac Thrombi and Emboli:TEE is indicated for the following: Evaluation of the left atrium and atrial appendage for clot, when clot is not visualized on TTE; Evaluation for an ASD, patent foramen ovale or atrial septal aneurysm with clot; and Evaluation of the mitral valve in patients with a history of emboli. Cardiac/Pericardial Masses and Other Pericardial Disease: TTE and TEE have comparable sensitivity in the assessment of right heart masses. Therefore, TEE is indicated for the following: Visualization of left atrial masses when needed to provide therapeutic direction (cystic vs. solid, attachment, infiltration); When cardiac mass lesions (including tumors on cardiac valves) are suspect and cannot be visualized on TTE, and TEE is needed for development of a management strategy; and To assess pericardial effusion when surface studies do not provide adequate information. "The risk of pericardiocentesis may be reduced by the use of echocardiographic guidance and monitoring of needle aspiration, particularly for loculated or small effusions." (ACC/AHA/ASE 2003 Guideline Update, pg. 39). Aortic Pathological Conditions and Diseases of the Great Vessels: TEE may be indicated when adequate visualization of the aortic root is not sufficient with TTE. TEE may be indicated for identification of aortic dissection, aortic ulceration, atherosclerotic plaque, and mural thrombotic material. TEE has a particularly high degree of sensitivity and specificity for aortic dissection. TEE is the technique that is indicated in examination of the entire aorta, especially in emergency situations. Because descending thoracic aortic aneurysms are difficult to visualize using TTE, TEE is recommended for this condition. Visualization of the superior vena cava and diagnosing various congenital and acquired abnormalities, such as vena caval thrombosis; Visualization of the proximal inferior vena cava, vena caval dilation and detection of thrombosis or extension of tumors from the inferior vena cava to the right-heart chambers; Visualization of all four pulmonary veins; and Evaluation of the heart and great vessels following blunt trauma to the chest (e.g., rupture or transsection of the aorta, acute dissection, hematoma, etc.) Congenital Heart Disease: TEE is indicated for the following: Patients with congenital heart disease postoperatively where fibrosis, echo opaque patches and prostheses, inadequate penetration, and acoustical shadowing can result in incomplete TTE data; Patients in which TTE is technically inadequate or anatomic definition is incomplete; Patients in whom a more precise definition of atrial, outflow tract and proximal pulmonary vascular anomalies by TEE can be critical to management strategies; and To assess complications of congenital heart surgery, visualization of shunt flow across atrial-septal defects, guidance of clamshell device to close atrial-septal defects, diagnosis of cor triatriatum, and detection of pulmonary valve abnormalities. Critically Ill Patients: TEE is indicated for the following: Management of the critically ill patient when TTE is otherwise contraindicated (e.g., chest or other major trauma) or inadequate (e.g., patient on a ventilator or with COPD, or in postoperative patients who are unable to be positioned for TTE); Patients with persistent hypoxemia having suspected right-to-left shunt; Patients with complications of myocardial infarction (ruptured septum, papillary muscle, or free wall); Hemodynamically unstable patients in whom TTE images are suboptimal; Evaluation of brain-dead patients being considered as cardiac donors; and Persistent unexplained fever when endocarditis or myocardial abscess is suspected and TTE is non-diagnostic. Interventional and Surgical TEE: TEE is indicated for the following: Guidance during percutaneous cardiac interventions such as during the creation of shunts, placement of septation devices, valvuloplasty procedures, endomyocardial biopsy, electrophysiologic studies/procedures, placement of septal or atrial appendage occluders or during percutaneous valve replacement; Intraoperative evaluation to assess prosthetic or repaired/reconstructed valve function, or the integrity/function of complex congenital heart repairs; Intraoperative evaluation to assess the integrity of the cardiopulmonary circulation in patients during lung or heart-lung transplants; and Intraoperative assessment for presence and/or severity of outflow tract obstruction or presence/repair of an intracardiac shunt; Intraoperative assessment of wall motion abnormalities in the case of acute deterioration in the patient's status, once the chest has been closed; and Only TEE done for specific diagnostic purposes may be separately payable during intraoperative use (TEE used for monitoring purposes is not separately payable). The results of the test must be used in making management decisions on the patient's intraoperative treatment. A covered service must include a complete interpretation/report by the performing physician, and must be available if requested. The pre-operative planning of valve repair for multiple etiologies of mitral regurgitation; In the assessment of mitral stenosis and in the accurate calculation of mitral valve area; Pre-operative planning for diagnosis and treatment of atrial septal defects; and Pre-operative and intraoperative planning for interventional cardiac procedures (e.g., transcatheter placement of occluders for atrial septal defects or patent foramen ovales, or paravalvular dehiscence or leaks; Intraoperative mapping for atrial ablation procedures. Three-dimensional echocardiography provides improved calculation of volumetric studies when compared to 2D echocardiography. However, its value in affecting clinical outcomes is not yet proven and is therefore not considered medically necessary. TEE is indicated for cardioversion in patients: Requiring urgent (not emergent) cardioversion for whom extended pre-cardioversion anticoagulation is not desirable; Who have had prior cardioembolic events thought to be related to intra-atrial thrombus; For whom anticoagulation is contraindicated and for whom a decision about cardioversion will be influenced by TEE results; and The service is performed by a physician; or The technical portion of the service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or Any non-physician personnel used by an IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropriate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropriate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met. (42 CFR, Section 410.33c) b. For the professional portion, an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting any one of the following requirements: The physician is board certified in Cardiovascular Diseases or Perioperative Transesophageal Echocardiography (National Board of Echocardiography); or The physician has Level II training in transesophageal echocardiography (including documentation of the performance of 25 esophageal intubations and 50 supervised interpretations), as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, or the equivalent of Level II training as set forth in that document, or The physician has been credentialed for this procedure by the hospital where the physician performs this service. CGS providers submitting claims for these services will be allowed a 2-year grace period (until 07/01/2011) to meet these standards. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A