TEE privileges

[Bertelman]

For the cardiac guys, where do you draw the line on "helping" with TEEs?

We have a busy EP lab with multiple groups. Some of our EP docs do their own TEE to r/o clot. Some have partners that are always available. One in particular occasionally can't find anyone to do it. So he asks us, and we oblige by placing the probe, clearing the appendage and writing the report. But I'm already involved in the GA for the PVI.

I had a new request today. Pt in the unit, 6 days post-op for AVR, needed TEE/CV. Again, couldn't find a cardiologist to do the TEE. They asked me, but I declined. I don't really care to get in the business of doing TEEs outside the peri-operative space.

Right call? Would you do the TEE? I used to think I was limited by my NBE cert, but many here have told me that's useless. I looked into my hospital privileges, which specifically list TEE. But the limits of my services are not clearly written.

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[abolt18]

Personally, I'm happy to do TEE anytime anyplace, so long as I'm available and have a way to bill for it/report it.

In training, we would roll the machine over to the ICU on occasion when cardiology was unavailable and we were. No big deal.

 

[Gimlet]

We recently took over EP TEEs from cardiology because our two electrophysiologists got sick of waiting for them to show up once the patient was induced. It only took a couple of days after we started doing that before I was approached to see if I would do the TEE before a cardioversion. I declined based on my comfort level inserting a probe on a patient under MAC sedation vs GA. We do help out in SICU occasionally by dragging a machine over from the OR to investigate a crumping patient, almost always at the CT surgeon’s request for someone postop.

 

[GassYous]

I think if you're doing the anesthesia, the tee is not billable separately. Seems like additional uncompensated risk.

 

[Ronin786]

Depends on how you want to be viewed in the hospital. Some cardiac anesthesia departments want to be the TEE masters of the OR and procedure suites but still want to be able to claim "OR responsibilities" when it's not convenient to staff EP/cath lab.

I agree that doing a TEE on the floor may not be best suited for an anesthesia department, but I would just caution about picking and choosing because somebody else will pick up the slack and potentially more.

 

[aneftp]

Would ur mind changed if colllected $800-1000 per exam? My brother does cardiac anesthesia and covers cardiac docs on weekends. He’s in hospital doctor ob anyways for the weekend. So an extra 30 min of work for that money isn’t bad.

 

[nimbus]

Would ur mind changed if colllected $800-1000 per exam? My brother does cardiac anesthesia and covers cardiac docs on weekends. He’s in hospital doctor ob anyways for the weekend. So an extra 30 min of work for that money isn’t bad.

The EPs at OP’s hospital would quickly learn to do their own exams if that were the case. All of our EPs do their own TEEs. These exams are usually 5min and less than 5min to report.

Also all of our cardioversions get anesthesia.

 

[Beeftenderloin]

In fellowship we did all of the above: clear appendage before ablations, crash TEEs in ICU patients, all the structural heart except mitraclip which we split 50/50 with cards, plus all MCS and pump cases.

Now hospital employed, doc only, we just do the the exams for pump cases and the occasional MCS. EPs clear their own appendages and the structural guys have a second cardiologist for mitraclips and watchmen. Even the rare TAVR under GA still has a surface echo tech come in for the post-deployment exam. We are paid by the shift and therefore stand to gain nothing but more work by expanding our TEE presence.

 

[pgg]

Would ur mind changed if colllected $800-1000 per exam? My brother does cardiac anesthesia and covers cardiac docs on weekends. He’s in hospital doctor ob anyways for the weekend. So an extra 30 min of work for that money isn’t bad.

Where's the $1000 coming from?

Is the cardiologist paying your brother $1000 to go do his TEEs for him so he can stay home?

Surely he's not billing Medicare and collecting $1000 per exam.

 

[Bertelman]

We practically own intra-op TEE. There were reasons why we did so. Early in our program, our cardiac surgery volume was on the low end (350). We did it because it was interesting. Now that we are doing 10+ watchman a week, and >1000 pumps a year, the story is a little different. In that time period we have transitioned from AMC to hospital employed.

So to Beef's point, we don't really have to go above and beyond, because I am also a shift employee. But I have a supportive admin. We have regular FMVs, and you better believe I list all the structural work we do. Do they compensate me for it? I'll never know. But I do know that the extensive hours we put in for structural imaging has allowed me to hire more cardiac docs, which means less call.

I get paid by shift. What would I rather do? Personally, I enjoy imaging Watchman all day over knees and Gyn robots. Plus, the cardiologists are employed by the hospital as well. They are probably compensated better than me, so ultimately it comes down to how the hospital wants to spend their money.

We have two newly graduated non-interventionalists who did a "Structural Imaging" fellowship during their Cardiology training. They are the only two that compete with us for imaging. Rumor has it, they won't be doing it much longer. They are also employed, but they have an RVU model in their contract. They probably lose thousands every day they sit imaging in a lab. And to be quite honest, outside of those two guys, an average cardiac anesthesiologist that was recently trained could run circles around a cardiologist imaging structural cases. Since we are there doing the anesthesia, I will do whatever it takes to squeeze more cases into the day and finish earlier.

 

[dchz]

Totally agree there is risk and no clear explicit compensation.

But it also depends on what the relationship is with the hospital/cardiologists.

Imagine this situation: huge hospital stipend, extremely respectful and collegial environment, 90%ile+ MGMA.

They are asking you to do a TEE on the floor. What u say?

 

[Bertelman]

Totally agree there is risk and no clear explicit compensation.

But it also depends on what the relationship is with the hospital/cardiologists.

Imagine this situation: huge hospital stipend, extremely respectful and collegial environment, 90%ile+ MGMA.

They are asking you to do a TEE on the floor. What u say?

Agree. There may have been more nuance than I originally posted.

I think it depends on the situation. Is there some urgency? I would have probably said yes. I was approached at 10 am, to do the case at 3 pm. Pt had been fed breakfast. The easy ask is to approach me, who's there anyways. But you really can't find anyone in the next 5 hours to perform this?

Otherwise, we tend to make room for their structural cases, including imaging, whenever we can. We have two cardiology groups. One always seems to have an available MD to pass a probe. The other one...just doesn't. And they have a similar number of employed docs.

Maybe next time I say yes.

 

[potcake76]

I think if you're doing the anesthesia, the tee is not billable separately. Seems like additional uncompensated risk.

Incorrect. The general rule by most of the Medicare carriers is that, as long as the TEE is being performed at the surgeon’s request, for a specific diagnostic reason (as opposed to simply for “monitoring” purposes), it is most certainly billable by the anesthesiologist. The anesthesiologist can bill for the probe placement only as well as for the full TEE service (probe placement + report + interpretation). Hope this helps.

 

[Bertelman]

That is definitely true for procedural TEE.

I'm not convinced that is true for a stand-alone diagnostic TEE.

 

[T-burglar]

We bill “ stand-alone “ diagnostic TEE if the surgeon documents the request and necessity . If it’s not in the OR, the other most common situation is in the ICU in the immediate pre and post op periods

 

[lotsapain]

Personally, I'm happy to do TEE anytime anyplace, so long as I'm available and have a way to bill for it/report it.

In training, we would roll the machine over to the ICU on occasion when cardiology was unavailable and we were. No big deal.

Thanks for that comment you are clearly from the old school row of folks not the snowflakes

 

[Robotic Wis-Hipple]

Incorrect. The general rule by most of the Medicare carriers is that, as long as the TEE is being performed at the surgeon’s request, for a specific diagnostic reason (as opposed to simply for “monitoring” purposes), it is most certainly billable by the anesthesiologist. The anesthesiologist can bill for the probe placement only as well as for the full TEE service (probe placement + report + interpretation). Hope this helps.

This is true aside from MitraClip and Watchman’s where the anesthesiologist cannot bill for the delivery of anesthesia and the echo.

The reality is most of the cases where you are doing an echo (afib clot r/o, pre-DCCV, endocarditis r/o, structural heart, and intraop for open heart surgery) the payor is garbage and it’s literally not worth enough to worry about. There’s a reason the cardiologists aren’t lining up to do the structural heart or EP echos. It’s the same reason they don’t have free cardiologists just hanging out for the random ICU TEE.

In this current practice environment our expertise and TEE privileges are best leveraged as making us a value for the department. Your surgeons will appreciate it (and trust you as you did the intraop) and the hospital will consider it a value add. Not that it actually makes you any money however.

 

[Bertelman]

Last I checked, you can bill maybe 200 for structural. If you’re a busy center, it’s not a lot, but it’s worth billing.

 

[Robotic Wis-Hipple]

Last I checked, you can bill maybe 200 for structural. If you’re a busy center, it’s not a lot, but it’s worth billing.

You cannot bill TEE as the hands on provider for MitraClip or Watchman. So utilizing a second anesthesiologist or CRNA to capture maybe $200 is a losing equation unless you’re already running 4:1 supervision with your CRNAs in structural heart cases.

TAVRS are mostly done as sedation with a TTE echo tech to spot check post deployment.

So that leaves the random PFO/ASD closures etc where you can bill TEE.

My point is the TEE is more valuable to you as a value add to the hospital and a way to bargain for improved $ or commitment to your service line than it is a direct revenue source. Certainly bill for it when you can but don’t say no for billing reasons.

 

[Bertelman]

You cannot bill TEE as the hands on provider for MitraClip or Watchman. So utilizing a second anesthesiologist or CRNA to capture maybe $200 is a losing equation unless you’re already running 4:1 supervision with your CRNAs in structural heart cases.

TAVRS are mostly done as sedation with a TTE echo tech to spot check post deployment.

So that leaves the random PFO/ASD closures etc where you can bill TEE.

My point is the TEE is more valuable to you as a value add to the hospital and a way to bargain for improved $ or commitment to your service line than it is a direct revenue source. Certainly bill for it when you can but don’t say no for billing reasons.

I agree that TEE is a value more than it is a revenue. We never use the same staff for the anesthetic and the TEE. So I bill for the TEE. We rarely run 4:1. And the doc doing TEE has more on his plate than imaging.

 

[itwasalladream]

I believe you can still bill the non-structural TEE code for watchman and mitraclip. 93312 plus all the add on modifiers probably gets $120-140 payment last I checked. 93355 probably gets 200+. The difference isn't that big, and not needing to keep a free MD around might make up for it depending on volume, practice setting, etc. We do that for TAVRs if we're doing TEE because we're solo. It's not something I would want to do solo for mitraclip since they require longer periods of staring at the echo, but that's a patient safety concern and separate from billing. A few years ago I heard the ASA was lobbying to allow 93355 and anesthesia to be billed by the same person, but nothing seems to have come of it.