CPT® Code 93350

Quick Reference

• Code definition: CPT 93350 covers transthoracic echocardiography performed at rest and during cardiovascular stress (treadmill, bicycle, or pharmacologic), with real-time 2D imaging, M-mode recording when performed, interpretation, and report. The code captures the echo component only; it does not include continuous ECG monitoring or physician supervision of the stress portion.
• Key billing rule: MUE = 1; only one unit per beneficiary per date of service. PC/TC Indicator = 1 applies, meaning Modifier 26 and TC splits are both valid and commonly required in facility settings.
• Modifier essentials: Modifier 26 when the cardiologist interprets only (facility setting); TC when the entity bills equipment and staff only; Modifier 59 with extreme caution when a distinct resting study is separately medically necessary on the same date.
• Documentation must-have: The report must document stress modality (treadmill protocol with METs achieved, bicycle watts, or pharmacologic agent with dosing), hemodynamic response at rest and peak, and a wall motion comparison between rest and stress phases with quantified ejection fraction.
• Top confusion point: Using 93350 when the interpreting physician also supervised continuous ECG monitoring during the stress. That scenario requires 93351, not 93350. Reporting 93350 in that setting undercodes the service and leaves revenue uncaptured.
• Bundling alert: Resting echo codes (93306, 93307, 93308) are NCCI-bundled into 93350 on the same date. Separate billing of these requires a distinct clinical indication with independent documentation, which is uncommon and audit-prone.
• Multiple procedures reduction: Multiple Procedures Indicator = 6 triggers special cardiovascular diagnostic payment reduction rules on the technical component when multiple diagnostic cardiovascular services are billed on the same date [1].

When to Use This Code

Clinical Indications

93350 is appropriate when a cardiologist or other qualified health care professional (QHP) performs and interprets the echocardiographic study but does NOT supervise continuous ECG monitoring during the stress portion. Clinically, this code applies to:

• Evaluation of known or suspected coronary artery disease (CAD), where new or worsening regional wall motion abnormalities during stress indicate myocardial ischemia
• Assessment of myocardial viability in patients with prior infarction or suspected hibernating/stunned myocardium
• Hemodynamic evaluation of valvular heart disease under stress (particularly aortic stenosis with low gradient, and mitral regurgitation severity during exertion)
• Risk stratification prior to intermediate or high-risk non-cardiac surgery when resting evaluation is insufficient per ACC/AHA criteria [6]
• Evaluation of exertional symptoms (chest pain, dyspnea, syncope, palpitations) when resting echo and ECG are inconclusive
• Post-revascularization assessment of procedural success and residual ischemia

Scope and Setting

The stress modality captured by this code includes treadmill exercise, bicycle ergometry, or pharmacologically induced stress (typically dobutamine for patients unable to exercise). Both modalities are reported with the same code.

93350 applies regardless of whether Doppler components are documented during the stress study. Since the 2023 CPT restructuring, Doppler analysis performed as part of the stress protocol is considered integral to the study and is not separately billable [7].

Place of service affects how the code is billed rather than which code applies. In the physician office (POS 11), the cardiologist who owns the equipment, performs the study, and interprets it bills globally with no modifier. In hospital outpatient (POS 22) or off-campus HOD (POS 19) settings, the physician bills with Modifier 26 and the facility bills TC.

Code Differentiation Table

The single most critical differentiator is ECG supervision. If the physician signing the echo report also supervised the continuous ECG during stress, 93351 is required. If someone else handled ECG supervision, or if no continuous ECG monitoring was supervised, 93350 is correct. These two codes are mutually exclusive; never report them together [1].

flowchart TD
    A[Stress echo performed] --> B{Did interpreting physician supervise continuous ECG monitoring?}
    B -- Yes --> C[Use 93351]
    B -- No --> D{Was ECG stress component performed by a separate provider?}
    D -- Yes, separately billable --> E[93350 + 93016/93017/93018 as applicable]
    D -- No ECG supervision billed --> F[93350 only]
    C --> G{Echocardiographic contrast used?}
    F --> G
    E --> G
    G -- Yes --> H[Add 93352]
    G -- No --> I[Done]

Billing and Modifier Rules

PC/TC Component Billing

PC/TC Indicator = 1 means 93350 follows standard diagnostic test splitting rules [1]:

• Global (no modifier): One provider or group owns the equipment, performs the study, and provides the interpretation. Common in private cardiology offices.
• Modifier 26: Physician provides interpretation and written report only. The facility or another entity owns the equipment and bills TC. Required when a cardiologist reads a study performed at a hospital or another facility's equipment.
• TC: Entity (hospital, outpatient facility) bills for equipment, technologist, and overhead only. No interpretation included.

Modifiers 26 and TC are mutually exclusive on the same claim line.

Add-On Codes

NCCI Bundling and MUE

• 93350 + 93306/93307/93308: NCCI bundles the resting echo codes as component services. Do not separately bill the resting phase of a stress study. Modifier 59 applies only when a genuinely separate, complete resting study is performed for a distinct clinical indication with independent documentation. This scenario is rare and carries significant audit risk.
• 93351 + 93016 or 93017: These component stress test codes are bundled into 93351. Never separately bill them alongside 93351.
• 93350 + 93015: When 93350 is reported and a separate physician performs all components of the stress ECG (supervision, tracing, interpretation), 93015 may be separately billable. NCCI interaction depends on provider relationship; verify current PTP edit files [4].
• MUE = 1: One stress echo per beneficiary per date of service. A second study on the same date requires a distinct clinical indication and is unlikely to pass medical necessity review.

Documentation Essentials

Required Elements

Every stress echo report must contain:

• Clinical indication linked to a specific ICD-10-CM code; the diagnosis must appear in the ordering documentation and the interpreting report
• Stress modality and protocol: treadmill protocol name (e.g., Bruce), stage achieved, METs reached; bicycle ergometry watts achieved; or pharmacologic agent (e.g., dobutamine), dosing, infusion rate, and patient response
• Hemodynamic data: resting and peak heart rate, blood pressure at each stage, percentage of maximum predicted heart rate achieved, and reason for termination
• Resting echocardiographic findings: baseline wall motion by segment, quantified ejection fraction (numeric percentage, not a range descriptor), chamber dimensions, and valvular assessment
• Stress echocardiographic findings: wall motion at peak stress compared segment by segment to rest, notation of any new or worsening regional wall motion abnormalities, and EF at peak stress
• Image quality statement: if contrast (93352) was administered, the report must document which segments were inadequately visualized without contrast and confirm the number of affected segments
• Physician signature on the final interpretation; attestation language is required in teaching settings

If 93351 is being considered instead of 93350, the record must also contain the continuous ECG tracing, rhythm interpretation, and ST-segment analysis from the stress portion.

Audit Red Flags

Auditors flag these documentation patterns specifically for stress echo claims:

• Ejection fraction described qualitatively ("normal," "mildly reduced") rather than quantified numerically
• Wall motion assessment limited to a global statement rather than segmental analysis comparing rest to stress
• No documented reason for termination of stress (critical for demonstrating the study reached diagnostic adequacy or appropriate endpoint)
• Contrast use (93352) billed without documentation of suboptimal image quality; the record must name specific segments that could not be adequately visualized
• Repeat stress echo within a short interval without a documented change in clinical status, symptoms, or a new cardiac event

Medicare, Commercial, and Medicaid Payer Rules

Medicare

93350 is covered under Medicare Part B as a diagnostic cardiac imaging service. Coverage requires medical necessity supported by the clinical indication in the medical record [5].

Multiple MACs maintain LCDs governing stress echocardiography and cardiovascular stress testing. LCD coverage criteria are jurisdiction-specific; verify the applicable LCD for your MAC (Novitas, CGS, Noridian, NGS, WPS, Palmetto GBA, First Coast) via the CMS Medicare Coverage Database [5]. Typical medical necessity criteria include: exertional symptoms (chest pain, dyspnea, palpitations, syncope) with an intermediate pretest probability for CAD; known CAD with change in clinical status; pre-operative cardiovascular risk stratification in patients with intermediate or high surgical risk per ACC/AHA criteria; and stress assessment of valvular hemodynamics.

Multiple Procedures Indicator = 6 means the technical component of 93350 is subject to special cardiovascular diagnostic payment reduction when billed on the same date as other diagnostic cardiovascular imaging services (e.g., nuclear stress test). Verify current CMS reduction percentages, as they update annually [1].

Site-of-service payment differentials apply. Non-facility (office) RVUs are higher than facility RVUs for physician payment, because the practice expense component shifts to the facility when the service is provided in a hospital outpatient setting.

Commercial Payers

Prior authorization requirements vary by payer and plan. Stress echo is often subject to prior authorization for non-urgent indications at major commercial payers, particularly when performed in an outpatient setting. Verify authorization requirements before scheduling elective studies.

Some commercial payers apply automated bundling edits that deny 93306 or 93308 billed on the same date as 93350, consistent with NCCI logic. Others may auto-downcode 93351 to 93350 when documentation does not explicitly support physician supervision of continuous ECG monitoring; review remittance advice carefully for these adjustments.

Medicaid

Coverage and medical necessity criteria for stress echocardiography vary substantially by state and managed Medicaid plan. Verify prior authorization and frequency requirements with the applicable state Medicaid agency or managed care organization before service.

Common Denials and Prevention

93351 billed when 93350 is correct (or vice versa) Payers deny claims when the documentation does not support the billed code. If 93351 is billed but the record shows the cardiologist only interpreted the echo and did not supervise continuous ECG monitoring, the claim will be adjusted to 93350 or denied. Conversely, if the cardiologist supervised the ECG stress but 93350 was submitted, the facility's TC claim and the supervising physician's 93016 claim will conflict.

Prevention: Establish a documentation workflow that captures ECG supervision separately from echo interpretation. The interpreting physician's report should explicitly state whether they supervised the stress ECG monitoring.

93306 or 93308 denied as bundled NCCI edits automatically deny resting echo codes billed on the same date as 93350 or 93351. This is a high-volume denial pattern in cardiology practices that have not updated their charge capture rules [4].

Prevention: Remove 93306, 93307, and 93308 from same-day charge triggers when 93350 or 93351 is billed. If a genuinely distinct resting study was performed, attach Modifier 59 with supporting documentation that demonstrates the separate clinical indication and independent documentation. Prepare for payer scrutiny; consider proactive documentation in the report.

93352 denied for missing contrast justification Payers require documentation that echocardiographic contrast was medically necessary, typically requiring that two or more myocardial segments were not adequately visualized without contrast [1].

Prevention: The interpreting report must name the specific segments affected and state the contrast indication before describing contrast-enhanced findings. A generic "contrast used to improve image quality" statement is insufficient.

Modifier 26 missing in facility setting When a cardiologist interprets a study performed at a hospital or outpatient facility but bills 93350 globally, the hospital's TC claim creates a duplicate billing conflict and the physician's claim may be denied or adjusted.

Prevention: Billing systems serving cardiologists who read studies at facility-owned equipment must automatically append Modifier 26 when POS is hospital outpatient, ED, or similar facility settings.

Frequency limitation denial Medicare and many commercial payers will deny a repeat stress echo performed within a short interval (often 12 months) without documented clinical justification for repeat testing.

Prevention: The order and the report must document the specific clinical change (new symptoms, post-revascularization, clinical deterioration) that justifies repeat testing. Reference the prior study date and explain why results are no longer representative of the patient's current status.

Coding Scenarios

Scenario 1 (Office, global billing): A 62-year-old with stable angina (I20.8) presents to a private cardiology practice. The cardiologist performs a treadmill exercise stress echo, supervises continuous ECG monitoring throughout, and provides the written interpretation. The practice owns the ultrasound equipment.

Correct coding: 93351, no modifier, primary diagnosis I20.8

Why: The physician performed the echo AND supervised continuous ECG monitoring. 93351 captures both components globally. Using 93350 here would undercode the service and miss the ECG supervision component.

Scenario 2 (Hospital outpatient, split billing): A 68-year-old with known atherosclerotic heart disease (I25.10) undergoes dobutamine stress echo in the hospital outpatient department. A hospital sonographer performs the technical portion; the cardiologist interprets remotely and provides the written report. The cardiologist did not supervise the dobutamine infusion or ECG monitoring.

Correct coding: Physician: 93350-26 with I25.10. Hospital: 93350-TC with I25.10.

Why: The cardiologist interpreted the echo study only; the hospital supervised the stress and owns the equipment. 93350 (not 93351) applies because the physician did not supervise continuous ECG monitoring. Both parties bill 93350 with their respective component modifier.

Scenario 3 (Contrast addition): A 58-year-old with exertional dyspnea (R06.09) undergoes exercise stress echo. At rest, the anterolateral and inferolateral walls cannot be adequately visualized. Definity contrast is administered; the report documents that two segments were non-diagnostic without contrast and names them specifically.

Correct coding: 93350 (or 93351 if ECG supervision applies) + 93352, primary diagnosis R06.09

Why: 93352 is an add-on code always listed in addition to the primary stress echo code. The report's explicit documentation of non-visualized segments supports the add-on; a claim without this documentation will be denied.

Scenario 4 (Pre-operative, medical necessity nuance): A 74-year-old scheduled for elective hip replacement undergoes dobutamine stress echo ordered for pre-operative cardiovascular clearance. Primary diagnosis: Z01.810. The cardiologist performs echo and supervises ECG monitoring in the outpatient cardiology clinic.

Correct coding: 93351 globally (office/clinic), primary diagnosis Z01.810

Why: The cardiologist performs all components. Pre-operative indications are covered when ACC/AHA criteria for intermediate or high surgical risk are met [6]. Verify coverage under applicable MAC LCD before billing; not all pre-operative stress tests are automatically covered without documented guideline-based indications in the medical record.

Related Codes

• 93351: Stress echo with continuous ECG monitoring and physician supervision; use when interpreting physician supervises the stress ECG component
• 93352: Contrast agent add-on for stress echo; always paired with 93350 or 93351 when contrast administered
• 93306: Complete resting transthoracic echo with Doppler; NCCI-bundled with 93350 on same date
• 93015: Cardiovascular stress test, global; stress ECG service that may be separately billable when a different provider performs all ECG components alongside 93350
• 93016: Cardiovascular stress test, supervision only; component-level billing with 93350 when different physician supervises ECG stress
• 93356: Myocardial strain imaging, speckle tracking; add-on when speckle tracking performed and documented with 93350 or 93351
• 0439T: Myocardial contrast perfusion echocardiography; add-on for perfusion assessment, distinct from 93352 (endocardial border contrast)

Sources

1. CPT Code 93350 Official Description and CMS PFS Indicators — CMS Physician Fee Schedule; verified via local CPT database: active code, MUE=1, PC/TC Indicator=1, Multiple Procedures Indicator=6
2. CPT Code 93351 Official Description and CMS PFS Indicators — CMS Physician Fee Schedule; active code, MUE=1, PC/TC Indicator=1
3. CPT Code 93352 Official Description and CMS PFS Indicators — CMS Physician Fee Schedule; active add-on code, MUE=1, PC/TC Indicator=0
4. CMS NCCI Policy Manual, Medicine Chapter — CMS; bundling rules for cardiovascular diagnostic services; verify current quarterly PTP edit files
5. CMS Medicare Coverage Database, Stress Echocardiography LCDs — CMS and MAC contractors; medical necessity criteria vary by jurisdiction
6. ACC/AHA Guideline on the Evaluation and Diagnosis of Chest Pain — ACC/AHA, 2021; clinical indications for stress echocardiography including pre-operative risk stratification
7. AMA CPT Assistant, Echocardiography Guidance — AMA (subscription required); 93350/93351 component reporting and 2023 echocardiography code restructuring; verify via AMA CPT Assistant subscription