Echocardiogram CPT Codes

Echocardiography coding spans 18 CPT codes across transthoracic, transesophageal, and stress modalities, with layered add-on code logic and a provider-split structure unique to TEE that generates routine claim errors. This guide walks through the approach, completeness, Doppler, and provider-split decisions that drive code selection, along with the bundling rules auditors examine most closely.

What the Procedure Involves

Echocardiography uses high-frequency ultrasound to produce real-time 2D images of cardiac structures, supplemented by M-mode recording, pulsed wave and continuous wave spectral Doppler for blood flow velocity measurements, and color flow Doppler mapping for visual flow assessment.

For transthoracic echocardiography (TTE), the sonographer or cardiologist positions an external transducer on the chest wall to acquire standard views: parasternal long and short axis, apical four-chamber, two-chamber, three-chamber, and subcostal windows. A complete study documents left and right ventricular size and function, all four valves, pericardium, and great vessel origins per ACC/AHA protocol.

For transesophageal echocardiography (TEE), the provider passes a probe into the esophagus or stomach under moderate sedation or anesthesia. TEE provides superior visualization of posterior structures (left atrium, pulmonary veins, interatrial septum, mitral valve) and is used diagnostically and intraoperatively for valve repair guidance, hemodynamic monitoring, and structural procedure oversight. The compliance distinction between diagnostic TEE (93312) and monitoring TEE (93318) hinges on whether the encounter generates a formal written interpretation and report.

Stress echocardiography adds rest and post-stress image acquisition to resting TTE, using treadmill, bicycle, or pharmacological (dobutamine, regadenoson) protocols.

Key variables driving code selection: (1) approach, transthoracic or transesophageal; (2) population, standard cardiac evaluation or congenital anomaly evaluation; (3) completeness, complete or limited/follow-up; (4) Doppler modalities performed; (5) whether one provider handles both TEE probe placement and interpretation or two separate providers split those components; (6) whether 3D postprocessing is performed; and (7) diagnostic versus intraoperative monitoring intent for TEE.

The congenital codes (93303, 93304, 93315-93317) are not age-restricted. They apply whenever the clinical indication is evaluation or follow-up of a congenital cardiac anomaly, whether in a pediatric patient or a 45-year-old with a known bicuspid aortic valve.

Quick Reference Table

Primary Echocardiography CPT Codes

Add-On Codes

Commonly Paired ICD-10-CM Diagnoses

Code Selection Decision Logic

Start with approach: transthoracic or transesophageal. Stress echocardiography is always transthoracic and branches separately. Within TTE, the next decision is standard versus congenital indication. Within TEE, the next decision is diagnostic versus monitoring intent.

graph TD
    A[Echocardiogram Ordered] --> B{Approach}
    B -->|Transthoracic| C{Stress Protocol?}
    B -->|Transesophageal| D{Purpose}

    C -->|No - Resting TTE| E{Congenital Anomaly Indication?}
    C -->|Yes - Stress Echo| F{ECG Monitoring Supervision by Same Provider?}

    E -->|Standard Adult| G{Completeness and Doppler}
    E -->|Congenital| H{Completeness}

    G -->|Complete with Spectral and Color Doppler| G1[[93306](https://www.codingahead.com/cpt/codes/93306)]
    G -->|Complete without Doppler| G2[[93307](https://www.codingahead.com/cpt/codes/93307)]
    G -->|Follow-up or Limited| G3[[93308](https://www.codingahead.com/cpt/codes/93308)]

    H -->|Complete| H1[[93303](https://www.codingahead.com/cpt/codes/93303)]
    H -->|Follow-up or Limited| H2[[93304](https://www.codingahead.com/cpt/codes/93304)]

    F -->|No| F1[[93350](https://www.codingahead.com/cpt/codes/93350)]
    F -->|Yes| F2[[93351](https://www.codingahead.com/cpt/codes/93351)]

    D -->|Diagnostic with Formal Report| J{Congenital Anomaly?}
    D -->|Intraoperative Monitoring - No Formal Report| M[[93318](https://www.codingahead.com/cpt/codes/93318)]

    J -->|Standard| K{Single or Split Provider?}
    J -->|Congenital| L{Single or Split Provider?}

    K -->|Single Provider - Global| K1[[93312](https://www.codingahead.com/cpt/codes/93312)]
    K -->|Split - Probe Placement Only| K2[[93313](https://www.codingahead.com/cpt/codes/93313)]
    K -->|Split - Interpretation Only| K3[[93314](https://www.codingahead.com/cpt/codes/93314)]

    L -->|Single Provider - Global| L1[[93315](https://www.codingahead.com/cpt/codes/93315)]
    L -->|Split - Probe Placement Only| L2[[93316](https://www.codingahead.com/cpt/codes/93316)]
    L -->|Split - Interpretation Only| L3[[93317](https://www.codingahead.com/cpt/codes/93317)]

Common errors at each branch:

• Selecting 93306 when only 2D imaging was performed without Doppler. Use 93307 as the base, then add 93320 and 93325 if those services were performed.
• Using adult standard TTE codes for a patient with a known congenital defect undergoing anomaly-specific surveillance. The congenital codes (93303, 93304) apply regardless of age.
• Billing 93312 when the anesthesiologist placed the probe and a separate cardiologist interpreted the images. Use 93313 + 93314, not 93312.
• Billing 93312 for intraoperative hemodynamic monitoring with no formal written report. The correct code is 93318.

Code-by-Code Breakdown

93306 — TTE, Complete, with Spectral and Color Doppler

AMA Descriptor: "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography."

This is the standard code for a complete adult transthoracic echo with full Doppler. Spectral Doppler (93320) and color flow Doppler (93325) are definitionally bundled; billing them separately constitutes unbundling and generates an NCCI edit denial. A "complete" study requires comprehensive assessment of both ventricles, all four valves, and pericardium per facility protocol.

PC/TC indicator 1 allows modifier 26 (professional component) and TC (technical component) splitting when the interpreting cardiologist and the technical facility are separate entities. MUE is 1 per date of service.

Common confusion: Some billing staff add 93320 and/or 93325 to 93306, mistakenly treating Doppler as a separately billable enhancement. These are already in the code descriptor. Do not add them.

93307 — TTE, Complete, without Doppler

AMA Descriptor: "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography."

This code is the correct primary when reporting Doppler add-ons separately. Unlike 93306, it does not bundle Doppler; add 93320 for spectral and 93325 for color when those services are documented. In current cardiology practice, performing a complete structural study without any Doppler is uncommon; auditors look closely at 93307 claims to confirm the documentation actually supports the absence of Doppler integration.

The combination of 93307 + 93320 + 93325 is legitimate when documentation is clear, but the combined reimbursement approaches 93306. Auditors review these combinations for correct code selection.

93308 — TTE, Follow-up or Limited Study

AMA Descriptor: "Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study."

Used for serial monitoring studies (e.g., LV ejection fraction surveillance in heart failure management) or targeted examinations where a complete multi-structure assessment is not clinically required. The record must document the limited scope or the follow-up nature of the study.

Add 93321 (spectral Doppler, follow-up) and 93325 (color flow) when those services are separately documented. Billing 93308 for a study that meets the complete-study definition leaves reimbursement on the table; billing 93306 for a demonstrably limited study is upcoding.

93303 / 93304 — TTE for Congenital Cardiac Anomalies

93303 Descriptor: "Transthoracic echocardiography for congenital cardiac anomalies; complete." 93304 Descriptor: "Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study."

These codes apply to any patient when the indication is evaluation of a congenital cardiac anomaly. The clinical note must document the specific congenital condition. Unlike 93306, these codes do not bundle Doppler: add 93320 and 93325 to 93303, or 93321 and 93325 to 93304, when those services are performed. Add 93319 for 3D postprocessing.

PC/TC indicator 1; MUE 1.

93312 — TEE, Complete, Single Provider (Global)

AMA Descriptor: "Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report."

This global code is used when the same provider performs probe placement AND generates the interpretation and report. PC/TC indicator 1 allows a TC/26 split at the billing entity level (e.g., hospital bills TC, cardiologist bills 26). When two different individual providers physically split the work, do not use 93312; use 93313 (probe placement provider) plus 93314 (interpreting provider) instead.

Add 93319 for 3D postprocessing. Add 93320 or 93321 and 93325 when spectral and color Doppler are performed beyond the base 2D acquisition.

93313 / 93314 — TEE, Split Billing

93313 Descriptor: "...placement of transesophageal probe only." 93314 Descriptor: "...image acquisition, interpretation and report only."

These component codes are used when one provider places the probe (typically an anesthesiologist or cardiac surgeon, billing 93313) and a separate provider performs image acquisition and interpretation (cardiologist, billing 93314).

93313 carries PC/TC indicator 0 (Physician Service Code), meaning it is inherently professional component only. Do not apply modifier TC or 26 to 93313. 93314 carries indicator 1 and can be split with 26/TC at the entity level.

These codes and 93312 are mutually exclusive. Billing 93312 alongside either 93313 or 93314 for the same encounter triggers an NCCI violation.

93315 / 93316 / 93317 — TEE for Congenital Anomalies

These parallel 93312, 93313, and 93314 exactly, applied when TEE is performed for congenital cardiac anomaly evaluation. 93315 is the global code; 93316 (probe placement, PC indicator 0, no TC/26 modifier) and 93317 (interpretation, PC indicator 1) are the split components. The same provider-split logic and mutual exclusivity rules apply.

93318 — TEE for Monitoring Purposes

AMA Descriptor: "Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis."

The compliance distinction here is documentation intent: monitoring (93318) versus diagnostic reporting (93312). Monitoring TEE generates no separate formal written report; findings guide immediate clinical decisions intraoperatively. When the provider generates a signed written diagnostic interpretation and report, 93312 applies, not 93318. Auditors reviewing cardiac surgical cases look for the presence or absence of a formal echo report to validate this code selection.

PC/TC indicator 1; MUE 1.

93319 — 3D Echocardiographic Imaging and Postprocessing (Add-On)

AMA Descriptor: "3D echocardiographic imaging and postprocessing during transesophageal echocardiography, or during transthoracic echocardiography for congenital cardiac anomalies..."

Global days ZZZ (add-on only); PC/TC indicator 0. This add-on is restricted to TEE procedures and congenital TTE. It cannot be added to standard adult TTE codes (93306, 93307, 93308). Documentation must confirm 3D image acquisition and postprocessing were performed and that findings contributed to the clinical assessment.

93320 / 93321 / 93325 — Doppler Add-Ons

93320: Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete. Global days ZZZ; MUE 2. 93321: Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited. Global days ZZZ; MUE 1. 93325: Doppler echocardiography color flow velocity mapping. Global days ZZZ; MUE 2.

The critical bundling rule: do not add 93320 or 93325 to 93306. That code already includes both Doppler modalities by descriptor. Adding them constitutes unbundling and will fail NCCI edits. These add-ons are appropriate with 93303, 93304, 93307, 93308, and all TEE codes (93312-93318).

93350 / 93351 — Stress Echocardiography

93350 Descriptor: TTE during rest and cardiovascular stress test, with interpretation and report. 93351 Descriptor: Same, including performance of continuous ECG monitoring with supervision by a physician or other qualified health care professional.

The distinction is whether the interpreting cardiologist also supervises continuous ECG monitoring during the stress protocol. If the same provider does both, use 93351. If a separate physician supervises the ECG component, that supervision is separately reportable under 93016, and 93350 covers the echo component.

Add 93352 when echocardiographic contrast is administered. The ECG tracing (93017) may be separately billable when documentation supports it as a distinct service from the echocardiographic interpretation.

93352 — Echocardiographic Contrast Agent, Stress Echo (Add-On)

AMA Descriptor: "Use of echocardiographic contrast agent during stress echocardiography."

Global days ZZZ; PC/TC indicator 0. Reported with 93350 or 93351 when a contrast agent is administered. Documentation must confirm the agent name and dose and provide clinical justification, typically that images were expected to be or were technically suboptimal without contrast.

Bundling, Unbundling and NCCI Edits

93306 bundles 93320 and 93325. Billing either Doppler add-on with 93306 triggers an NCCI edit denial. No modifier override is available because these services are included in the 93306 descriptor by definition. This is among the most common echocardiography unbundling errors encountered in cardiology billing audits.

93312, 93313, and 93314 are mutually exclusive. Billing 93312 with either component code constitutes a direct NCCI violation. When providers split the work, only the component codes are reported; the global code is not billed by either provider.

93351 includes physician ECG supervision. Separately billing 93016 (stress test supervision only) by the same provider on the same date as 93351 is duplicate billing. The ECG tracing (93017) and professional interpretation (93010 or 93018) may be separately reportable depending on the clinical record and payer policy.

93318 and 93312 are mutually exclusive on the same TEE encounter. Monitoring TEE and diagnostic TEE describe different service types for the same session; only one applies.

Add-on codes require a valid primary code on the same claim. If the primary echocardiography code is denied, all associated add-ons (93319, 93320, 93321, 93325, 93352) must be reversed. These codes cannot stand alone.

Medicare and Payer Rules

Medicare covers TTE and TEE for established cardiac indications under MACs' LCDs: heart failure evaluation (I50.9), valvular heart disease (I34.0, I35.1), cardiomyopathy (I42.0), endocarditis evaluation, pericardial disease, and congenital anomaly follow-up. Verify covered diagnoses and frequency limits against the specific MAC LCD for the billing state in the CMS Medicare Coverage Database. MAC LCDs vary by jurisdiction (Novitas, CGS, WPS, Palmetto, NGS, FCSO).

Coverage for echo ordered solely on the basis of chest pain (R07.9) typically requires accompanying clinical documentation of a cardiac workup that justifies echocardiography. Medicare does not cover echo as a screening study without a specific clinical indication.

Stress echocardiography (93350, 93351) requires documentation of the clinical indication, the stress protocol used, whether exercise stress was contraindicated (for pharmacological protocols), confirmation that adequate rest and stress images were obtained, and the interpreting physician's supervision role in ECG monitoring.

All primary echocardiography codes carry global days XXX, meaning they are not bundled into surgical global periods. The PC/TC indicator is 1 for most codes; indicator 0 for 93313, 93316, 93319, and 93352 (Physician Service Codes, not splittable with 26/TC).

Site-of-service determines RVU allocation. Cardiologists interpreting in a hospital-based lab bill the professional component only; the technical component is billed by the facility. Non-facility reimbursement is higher and applies to free-standing office settings where the physician owns the equipment.

For 93352, the contrast agent itself (perflutren lipid microspheres or similar) is separately reportable under the applicable HCPCS Level II drug code. Document agent name, dose, and route of administration.

When the same provider who performs TEE also administers moderate sedation, report the appropriate moderate sedation code (99151 for patients under 5 years; age-based codes apply for older patients). TEE is not on the CMS list of procedures for which moderate sedation is bundled; sedation is separately reportable. When an anesthesiologist provides anesthesia for TEE, anesthesia codes apply instead.

Documentation Checklist

1. Clinical indication: Specific diagnosis or signs/symptoms justifying the echocardiogram; must support medical necessity under the applicable LCD
2. Study completeness: Explicit statement that a complete study was performed per facility protocol, or documentation of limited scope with clinical rationale
3. Doppler modalities: Confirmation that spectral Doppler and/or color flow Doppler were performed when add-on codes are billed; absence of Doppler documentation must be clear when billing 93307
4. 3D imaging: Documentation of 3D image acquisition and postprocessing when 93319 is billed, with clinical contribution noted
5. TEE probe placement identity: When split billing applies (93313/93314 or 93316/93317), the record must identify which provider placed the probe and which generated the interpretation
6. TEE study intent: Monitoring studies (93318) should document continuous assessment nature; diagnostic TEE (93312-93317) requires a formal signed written interpretation and report
7. Stress protocol details: For 93350/93351, document stress type (exercise or pharmacological agent with dose), any contraindication to exercise, ECG monitoring supervision role, rest and post-stress image acquisition confirmation
8. Congenital indication: For 93303, 93304, 93315-93317, explicit documentation of the specific congenital cardiac condition under evaluation
9. Contrast use: For 93352, contrast agent name, dose, and clinical justification (typically suboptimal image quality without contrast)
10. Interpreting provider credentials: Interpreting physician NPI and credentials; supervision level for technical components when applicable

Common Billing Errors and Denial Prevention

1. Unbundling Doppler from 93306. Adding 93320 or 93325 to 93306 is a direct NCCI violation. These are included in the 93306 descriptor. The claim will deny on NCCI edits, and repeated patterns attract overpayment recovery attention.

2. Billing 93312 for intraoperative monitoring TEE. When TEE is performed for continuous intraoperative hemodynamic monitoring without generating a formal written interpretation and report, 93318 is the correct code. Billing 93312 constitutes upcoding; auditors will look for a signed written report to validate 93312, and its absence supports recoupment.

3. Billing 93312 and 93313 together. These are mutually exclusive. One provider, one code: global (93312) or component (93313). When providers split, only the component codes are reported.

4. Using standard adult TTE codes for congenital indications. A patient with known Ebstein anomaly, repaired tetralogy of Fallot, or any other congenital defect undergoing echocardiographic surveillance requires 93303 or 93304. Using 93306 or 93308 misrepresents the service and misses the correct congenital code path for add-ons (93320, 93325 are not separately billable with 93306 but are appropriate with 93303).

5. Billing 93351 and 93016 by the same provider. Physician ECG supervision during stress echo is included in 93351. Separately billing 93016 for the same supervision event by the same provider on the same date is duplicate billing.

6. Billing 93306 or 93308 without documenting completeness or limitation. The record must affirmatively state whether the study was complete per protocol or limited/targeted. "Echo performed" without completeness documentation is inadequate; payers will request records and may deny for incomplete documentation.

7. Missing contrast justification for 93352. Commercial payers and Medicare require documentation that contrast was medically necessary. Submitting 93352 without the agent name, dose, and clinical indication in the record will generate requests for additional documentation and likely denial.

8. Using deleted ICD-10-CM code Q21.1. Q21.1 (atrial septal defect, NOS) was deleted effective October 1, 2022, and expanded into subcategory codes (Q21.10, Q21.11, Q21.19). Claims with Q21.1 for dates of service after September 30, 2022 will reject on ICD-10-CM validation. Update code references and encoder crosswalks accordingly.

Clinical Scenario Examples

Scenario 1: Routine TTE for heart failure management A 68-year-old with non-ischemic dilated cardiomyopathy (I42.0) and heart failure (I50.9) presents for annual LV function assessment. The cardiologist performs a complete study with 2D imaging, spectral Doppler, and color flow Doppler. A formal interpretation and report are generated.

• Code: 93306
• Do not add 93320 or 93325; both are bundled
• Dx: I42.0, I50.9

Scenario 2: TEE for intraoperative mitral valve repair assessment During an open mitral valve repair, the cardiac anesthesiologist places the TEE probe intraoperatively for hemodynamic monitoring. Findings are communicated verbally to the surgical team in real time; no formal written echocardiography report is generated.

• Code: 93318 (monitoring TEE)
• Do not bill 93312; no formal diagnostic report exists
• If a cardiologist is called in and generates a separate written interpretation, add 93314 for their professional component

Scenario 3: TEE with split providers, 3D, and Doppler An adult patient with suspected mitral valve endocarditis undergoes diagnostic TEE. The anesthesiologist places the probe. A separate cardiologist acquires images, performs spectral Doppler, performs 3D postprocessing, and generates a formal written interpretation and report.

• Anesthesiologist bills: 93313
• Cardiologist bills: 93314 (with modifier 26 if facility bills TC separately) + 93319 (3D add-on) + 93320 (spectral Doppler add-on)
• Dx: I34.0

Scenario 4: Pharmacological stress echocardiography with contrast A 55-year-old with I25.10 and R07.9 undergoes dobutamine stress echocardiography. The interpreting cardiologist supervises continuous ECG monitoring throughout the protocol. Resting images are suboptimal; echocardiographic contrast is administered for both rest and stress acquisitions.

• Primary: 93351 (stress echo with physician ECG monitoring supervision)
• Add-on: 93352 (contrast use during stress echo)
• Do not separately bill 93016; ECG supervision is included in 93351
• Dx: I25.10, R07.9

Scenario 5: Congenital TTE follow-up in an adult A 32-year-old with surgically repaired ventricular septal defect presents for annual surveillance TTE. A complete study is performed with 2D imaging, spectral Doppler, and color flow Doppler. Documentation confirms the congenital indication.

• Primary: 93303 (TTE for congenital cardiac anomalies, complete)
• Add-ons: 93320 (spectral Doppler) + 93325 (color flow)
• Note: Unlike 93306, which bundles Doppler, 93303 does not; add-ons are appropriate and separately billable here
• Dx: applicable congenital anomaly code (verify current Q21.x subcategory for ASD-type defects)

Related Procedures and Cross-References

Sources

• AMA CPT 2025 Code Set: CPT descriptors for 93303-93352 verified against the CPT database, including 2025 descriptor revisions to 93320, 93321, and 93325
• CMS Medicare Physician Fee Schedule: PC/TC indicators, global days, and MUE values verified from the MPFS database for all listed codes
• CMS Medicare Coverage Database — MAC LCDs for echocardiography; covered indications and frequency limits by jurisdiction
• CMS National Correct Coding Initiative (NCCI) — PTP edit pairs for echocardiography codes
• ICD-10-CM FY2023 Tabular List: deletion of Q21.1 and expansion to Q21.10, Q21.11, Q21.19 effective October 1, 2022