Provider documentation required for billing myocardial strain imaging
I’m wondering what the provider documentation requirements are when reporting CPT® code 93356. What specifically must be documented to substantiate the myocardial strain imaging charge?
The code and full description are as follows:
93356 Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (List separately in addition to codes for echocardiography imaging)
Here is the description from CPT Changes, and it is best to base reporting on what this says:
Description of procedure 93356 The physician reviews request for service to clarify the indications for the procedure and determine the clinical questions that need to be answered by the myocardial strain echo examination. Analyze images of the acquired myocardial strain data (static and real-time) on an appropriate software program to determine regional and global longitudinal, radial, and/or circumferential strain and/or strain rates. Compare these data to previous studies, when available. Dictate a report and review the findings in detail with the referring physician.