Echocardiography is one of the most widely used non-invasive diagnostic tools in cardiovascular medicine. It plays a central role in evaluating cardiac function, valve disease, structural abnormalities, and hemodynamics. Because it is so frequently performed, proper billing and documentation of echocardiography services are highly scrutinized by payers and auditors.
This comprehensive guide outlines all major transthoracic, transesophageal, fetal, Doppler, and stress echocardiography CPT codes, along with billing rules, technical/professional splits, documentation requirements, modifier use, and common denial issues to support physicians, medical coders, and practice managers.
Understanding the Main Categories of Echocardiography
Echocardiography CPT codes fall into five major categories:
- Transthoracic Echocardiography (TTE) – 93303–93308
- Doppler Echocardiography – 93320–93325
- Transesophageal Echocardiography (TEE) – 93312–93318
- Stress Echocardiography – 93350–93351
- Fetal Echocardiography – 76825–76828
Each category has distinct billing rules, including when Doppler can be billed separately, what constitutes a complete study, and what documentation must be present to support each component.
Transthoracic Echocardiography (TTE): CPT 93303–93308
Transthoracic echocardiograms are the most commonly performed echo studies. Coding depends on whether the study is complete or limited, and whether congenital anomalies are present.
93303 – TTE for Congenital Cardiac Anomalies (Complete)
Use when imaging a patient with congenital heart disease requiring a comprehensive evaluation. Includes 2D, M-mode, and spectral and color Doppler when medically necessary.
93304 – TTE for Congenital Cardiac Anomalies (Follow-up or Limited)
Used for reassessment of congenital conditions without the full scope of a complete initial exam.
93306 – TTE Adult (Complete with Doppler & Color Flow Included)
Most common TTE code.
Includes:
- 2D imaging
- M-mode
- Spectral Doppler
- Color flow Doppler
Since Doppler is bundled, 93306 cannot be billed with 93320, 93321, or 93325.
93307 – TTE Adult (Complete without Doppler)
Includes:
- 2D imaging
- M-mode
- Does not include Doppler.
- Doppler services may be added using 93320, 93321, and 93325 (if performed and documented).
93308 – Limited TTE
Used for:
- Focused evaluation
- Follow-up studies
- “Quick look” echo for pericardial effusion, LV function, etc.
- Doppler can be added only if medically necessary and performed.
Documentation Requirements for TTE
All TTEs must include:
1. Indication for the Study
Examples:
- Heart failure/cardiomyopathy
- Suspected valve disease
- Pericardial effusion
- Chest pain
- Atrial fibrillation
- Follow-up for abnormal imaging
2. Required Imaging Components
For a complete study:
- 2D imaging
- M-mode (if used)
- Doppler and color flow (if included per code)
Limited studies require at least:
- One or more targeted views
- Documentation supporting the reason for limited testing
3. Interpretation & Final Report
Final report must include:
- LV size and systolic function (EF estimate required)
- RV size/function
- LA/RA size
- Valvular structure and function (stenosis/regurgitation)
- Wall motion abnormalities
- Pericardium evaluation
- IVC assessment when appropriate
4. Medical Necessity
Must clearly link symptoms/findings to the need for TTE.
Missing final interpretation or insufficient documentation is a primary cause of payer denials.
Doppler Echocardiography: CPT 93320–93325
Doppler services may be billed separately when not included in the primary echo code.
93320 – Spectral Doppler
For evaluation of:
- Valve velocities
- Pressure gradients
- LV inflow/outflow
- Pulmonary pressures
93321 – Limited Spectral Doppler
Used when only select components of the full spectral Doppler study are performed.
93325 – Color Flow Doppler
Typically used with:
- 93307
- 93308
Not separately billable with:
- 93303
- 93304
- 93306
Documentation for Doppler
Must include:
- Valve interrogations
- Flow velocities
- Gradients
- Interpretation of findings
Transesophageal Echocardiography (TEE): CPT 93312–93318
TEE involves invasive imaging with an esophageal probe and requires conscious sedation or anesthesia.
93312 – TEE Diagnostic, Including Probe Placement & Image Acquisition
Includes:
- Probe insertion
- Imaging
- Interpretation
- Do not bill 93312 if the provider only interprets images.
93313 – Probe Placement Only
Used rarely, typically by anesthesiologists or other providers.
93314 – Interpretation Only
Used when the cardiologist interprets the TEE but did not place the probe.
93316 – Probe Insertion with Guidance
Used when guidance is necessary for cardioversion or other procedures.
93317 – Image Acquisition Only
Technical component only.
93318 – TEE Monitoring
Used for intraoperative cardiac monitoring during surgery.
Does NOT include full diagnostic TEE.
Documentation Requirements for TEEs
TEE notes must include:
1. Medical Indication
Examples:
- Suspected endocarditis
- Embolic stroke evaluation
- Atrial thrombus rule-out
- Prosthetic valve assessment
- Intraoperative monitoring
2. Sedation Used
The type of sedation/anesthesia must be documented.
3. Probe Insertion Details
Indicate:
- Successful insertion
- Images obtained
- Any complications
4. Imaging Findings
A complete report describing:
- Valve morphology
- Thrombus presence/absence
- Aorta
- Wall motion
- Pericardium
- Prosthetic valve details
5. Interpretation Signed by Physician
Stress Echocardiography: CPT 93350 & 93351
Stress echo combines imaging with exercise or pharmacologic stress.
93350 – Stress Echocardiogram (Without Stress Test Supervision)
Includes:
- Baseline echo
- Post-stress echo
- Interpretation and report
Does not include:
- Stress test supervision (93016)
- ECG tracing (93017)
- ECG interpretation (93018)
93351 – Stress Echo with Stress Test Supervision
Includes:
- Supervision of exercise or pharmacologic stress
- Baseline and post-stress echo
- Interpretation and report
Documentation Requirements
Must include:
- Stress method (exercise, dobutamine, etc.)
- Duration and peak workload
- Hemodynamic response (HR, BP)
- Echo findings at baseline vs stress
- Wall motion analysis
- Conclusion (ischemia, normal response, etc.)
Incomplete stress measurements are a frequent source of denials.
Fetal Echocardiography: CPT 76825–76828
Used to assess fetal cardiac anatomy and function.
76825 – Fetal Echo, Complete
Includes:
- Four-chamber view
- Outflow tracts
- Aortic/ductal arches
- Rhythm assessment
76826 – Fetal Echo, Follow-up/Limited
76827 – Doppler Fetal Echo
Spectral Doppler evaluation of fetal cardiac structures.
76828 – Color Flow Doppler Fetal Echo
Key Modifier Rules in Echocardiography
Modifier 26 – Professional Component
Used when the physician interprets the echo (hospital setting).
Modifier TC – Technical Component
Used for the technical portion performed by a facility or imaging center.
Modifier 59 – Distinct Procedural Service
Required when Doppler studies are separately billable and not bundled.
Modifiers RT/LT
Required by some payers for fetal imaging.
Modifier 76/77 – Repeat Study
76 = same provider
77 = different provider
Payer-Specific Nuances & Prior Authorization Notes
Medicare
- TTE, TEE, and Doppler usually do not require prior authorization
- Strict on medical necessity
- Limited TTE (93308) is commonly down-coded if documentation doesn’t support it
Commercial Plans
Often require prior authorization for:
- Stress echo
- TEE
- Repeat echo studies
- Fetal echocardiography
Medicaid Programs
May require:
- Written justification for repeat studies
- Prior authorization for TEE or stress echo
- Additional risk factor documentation for TTE
Common Denials in Echocardiography
1. Downcoding of 93306 to 93307 or 93308
Occurs when:
- Doppler findings not documented
- Color flow not documented
- M-mode not documented (if applicable)
2. Unbundling Errors
Attempting to bill Doppler separately with 93306.
3. Missing Medical Necessity
Documentation must explain why the echo was needed.
4. Missing Interpretation Report
Unsigned or missing final reports lead to denials of:
- 93306–93308
- 93312–93318
- 93350–93351
5. No Documentation of Stress Metrics
Required for billing 93350/93351.
6. Repeat Studies Lacking Justification
Frequent audit trigger.
7. Incomplete TEE Documentation
Especially missing sedation/anesthesia details.
Compliance & Audit Risks
Echocardiography is a high-audit area due to:
- High utilization
- Frequent repeat testing
- Common upcoding from limited → complete studies
- Bundling misunderstandings
- Sedation documentation issues in TEE
Compliance Tips
- Echo reports must be complete, signed, and stored
- Document the exact components performed
- Avoid copy-paste templates
- Doppler studies must include measurable values
- For complete TTE, ensure all structures are documented
- The TEE sedation details must be included
- Stress echo must include workload, HR, BP, and wall motion comparison
Conclusion
Echocardiography billing requires a precise understanding of CPT code structures, imaging components, supervision rules, and payer guidelines. Distinguishing between complete and limited studies, understanding Doppler bundling, and ensuring detailed documentation are essential to avoid downcoding, denials, or audit exposure. Clear protocols and standardized reporting templates help ensure accuracy and compliance in echo billing workflows. Practices seeking structured billing review or documentation optimization may consult professional services such as Global Tech Billing LLC for guidance aligned with payer standards.
FAQs (5–8 Short, Factual)
1. What is the most commonly used echocardiogram CPT code?
93306 is the most commonly used code for a complete TTE, including Doppler and color flow.
2. When can Doppler echo codes be billed separately?
When billing 93307 or 93308, Doppler or color flow is medically necessary and performed.
3. What documentation is required for a complete TTE?
Indication, 2D imaging, M-mode (if used), Doppler, color flow findings, and a full interpretation.
4. What CPT codes apply to TEE?
93312–93318, depending on whether probe placement, imaging, or interpretation was performed.
5. Does a stress echo include the stress test supervision?
93350 does not; 93351 includes supervision plus imaging and interpretation.
6. Are repeat echocardiograms billable?
Yes, only if medically necessary and documented; frequent repeats require strong justification.
7. Why are echo studies often downcoded?
Incomplete documentation of Doppler or imaging components results in downcoding.
8. Do TEEs require sedation documentation?
Yes, sedation type, administration, and monitoring must be clearly documented.
