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2025 CPT code 93316

Transesophageal echocardiography (TEE) for congenital cardiac anomalies; placement of transesophageal probe only.

Follow all standard coding guidelines, including those provided in the CPT manual.

Modifiers may be applicable depending on the circumstances of the service. Consult the CPT manual for specific guidance.

Medical necessity for a TEE (93316) is established by the presence of clinical indications suggestive of congenital heart defects. These may include symptoms such as cyanosis, shortness of breath, murmurs, or other findings identified during the physical examination or other diagnostic procedures.Appropriate documentation supporting the clinical suspicion is crucial for establishing medical necessity.

The clinical responsibility for this procedure rests with the physician or qualified healthcare professional performing the transesophageal echocardiography. This involves preparing the patient (including sedation or anesthesia, if necessary), inserting and manipulating the transesophageal probe, acquiring and interpreting images, and generating a comprehensive report detailing findings and measurements.

IMPORTANT:Do not report 93316 in conjunction with 93355.

In simple words: This medical test uses ultrasound waves to create detailed images of the heart. A small tube with a sensor on the end is passed down the throat into the esophagus to get better views. It helps doctors find birth defects in the heart.

This CPT code, 93316, encompasses transesophageal echocardiography (TEE) specifically for the purpose of visualizing congenital cardiac anomalies. The procedure involves the placement of a transesophageal probe, which is a flexible tube with a transducer at its tip, guided down the patient's throat into the esophagus.This allows for detailed imaging of the heart. The code includes the acquisition of two-dimensional (2D) images using either multiple transducers or a rotating transducer.The procedure aims to identify any congenital abnormalities present in the heart's structure or function.Importantly, this code covers only the placement of the transesophageal probe;additional services such as image interpretation or other procedures are coded separately.

Example 1: A newborn infant is suspected of having a congenital heart defect. A TEE (93316) is performed to visualize the heart's structures and identify any abnormalities., A child with a history of congenital heart disease requires a follow-up TEE (93316) to assess the condition and the effectiveness of previous treatment., An adult patient presents with symptoms suggestive of a previously undiagnosed congenital heart defect. A TEE (93316) is performed as part of a comprehensive cardiac evaluation.

Patient demographics, medical history, reason for the procedure (clinical indication), images acquired during the TEE procedure, measurements obtained (if applicable), description of findings, including any abnormalities, and final written report.Documentation should clearly distinguish between probe placement and any associated interpretation or additional procedures.

** This code is for probe placement only.Interpretation and any additional procedures are reported with separate codes.

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