Society of Cardiovascular Anesthesiologists

Dear Dr. Forstot,

At our institution anesthesiologists bill for echocardiographic services through the Department of Anesthesiology and receive the same reimbursement as cardiologists from Medicare. I am not aware of a formal survey on this issue, but I know that the policy is determined by the local Medicare carrier and varies from location to location. My impression is that situations like yours, where the Medicare carrier denies payment because you are an anesthesiologist, exist in other regions but are the exception rather than the rule.

When we charge for an intraoperative echocardiogram, we carefully perform and document all required aspects of the service: insertion of the probe, acquisition of a complete, comprehensive diagnostic examination, interpretation of the images, and creation of a report, which goes on the patient's chart. We record and archive all of our studies and their reports. I have spoken with an anesthesiologist in another region who bills and receives payment for echo services who has gotten a letter from the local Medicare carrier stating that these services are not included in the anesthesia care. The issue has never come in my region as far as I know.

Dr. Fyfe's editorial was unfortunate in its reference to speculated "fraud and abuse" by an anesthesiologist trying to receive fair compensation for providing a valuable service. I have never heard of this charge actually being made and believe that those responding to the editorial have not felt this inappropriate remark deserved comment. Certainly, many cardiologists might be vulnerable to the same accusation when they over read an echo after the patient has left the OR, and the interpretation comes too late to influence the operation.

I think an important aspect of this issue is training and certification. Because you are certified by the National Board of Echocardiography in Perioperative TEE, I should think it would be more difficult for your carrier to maintain the position that TEE is a routine part of anesthetic care, considering the additional knowledge you have demonstrated. I wonder if the cardiologists receiving payment for similar services in your region have equivalent qualifications to perform TEE in the OR.

There appears to be little that national societies can do at this point, as these are essentially local issues. I would recommend meeting with the medical director of your Medicare carrier at some point being prepared to present your qualifications and how other regions differ in policy from yours. You can find your local Medicare carrier on the internet at www.hcfa.gov/medicare/incardir.htm. It is also important to keep in mind that provision of intraoperative echo-cardiographic services deserves consideration and compensation when negotiating contracts with managed care organizations. Be sure that those representing your position are aware of your efforts or you will undoubtedly be uncompensated.

By the way, what Medicare is reimbursing for echocardiographic services is not much and decreasing on a regular basis, but something is better than nothing.

I have taken the liberty to forward your message to Daniel Thys, the current chair of the American Society of Echocardiography Council on Intraoperative Echocardiography. I think the issue deserves discussion in this forum.

Jack Shanewise, MD
Department of Anesthesiology
Emory University School of Medicine
Atlanta, GA

Dear Dan and Steve,

I agree wholeheartedly with your October newsletter editorial regarding written communication of TEE findings. As cardiac anesthesia chief of a busy private practice cardiac program, I felt that the proper tools were not available for anesthesiologists to rapidly generate a preliminary TEE report form for the medical record. Therefore, I developed a form that has served us very well. One feature that makes my form easy to interpret is the following convention: normal findings are always checked in check boxes, while abnormal findings are circled. Therefore, a quick scan for the circled words allows readers to focus on the pathology.

Finally, it is my belief that a SCA-sponsored web site containing an educational "library" of interesting TEE videoclips would be of significant use to the SCA's membership. I know my division's perioperative TEE library contains many interesting videos, and by pooling many institutions' experiences, a worthwhile resource could be developed for little cost.

David R. Larach, MD, PhD
Chief, Division of Cardiac Anesthesiology
St. Joseph Heart Institute
Towson, MD

Dr. Thys,

It is with interest that I read your President's Message in the recent SCA newsletter. We are in agreement that it is concerning that Anesthesiologists are reluctant to write intraoperative TEE reports.

In an attempt to overcome this we incorporated a TEE report onto the reverse page of our anaesthetic record. This report was designed to take up minimal time and effort and only requires ticks / short remarks to be completed. This report is then filed in the patient notes for access by all other physicians. In addition we keep videotape recordings.

It would be my recommendation that Dr. Steven Konstadt and his task force improve / design a similar reporting sheet in their quest to develop a "Standard Report of Intraoperative TEE findings". I would furthermore suggest that this report form be made available on the SCA website for downloading by all institutions.

Bernhard J.C.J. Riedel, FCA
Royal Brompton & Harefield NHS Trust
United Kingdom

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