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A radiology practice that performs interventional procedures will want to be up to date on the use of documentation and coding techniques for Evaluation and Management (E&M) services.  These CPT^® codes in the 99xxx range are less commonly utilized in radiology practices.  Identifying circumstances where E&M services are billable, and then properly documenting and coding for them, will require a collaborative effort between the interventional radiologist (IR) and his or her coding team.

Consultations vs. Office Visits

A patient’s visit with the IR prior to a procedure can variously be considered a consultation, an office visit, or a component part of the procedure depending on the circumstances.  A “consultation” is defined as a service that:

• Requires an opinion or advice regarding the evaluation and management of a specific problem, and
• Is requested by another physician or other appropriate source.

The consultant’s opinion and any services that are ordered or performed must be documented in the patient’s medical record and communicated by written report to the requesting physician.   A consultation initiated by a patient or family member, but not requested by a physician, is not reported using consultation codes but rather will be reported using the office visit codes.   

Consultation codes normally carry a higher reimbursement than office visit codes for the same level of service.  However, note that Medicare will not allow the use of consultation codes, so for Medicare patients the regular Office Visit codes will be used in all cases for either a new or established patient.  A “new patient” is one who did not receive any professional services from the IR or another IR physician who belongs to the same group practice within the previous three years.  

The following table summarizes some of the more common E&M codes that will be used for outpatients in the IR clinic:

Determine if the service is separately billable

The initial visit might also be considered by Medicare to be a component part of the surgical procedure.  The rules that define payment for E&M services use a concept called the Global Period (GP).  The global period begins on the day of the procedure (or on the preceding day in the case of a 90-day GP) and, depending on the CPT code for the procedure, could run for 0, 10 or 90 days.  Generally, E&M visits for the purpose of deciding whether or not to perform a procedure are billable and payable if they occur outside of the GP.  During the GP, all services related to the procedure are included as a component part of the surgical package, and therefore are not separately reimbursable.  However, for a procedure with a 90-day GP, considered to be a “major surgery”, an E&M service performed on the same day or preceding day for the purpose of deciding whether to perform the procedure may be separately reported and payable with the addition of Modifier -57 (Decision for Surgery).

The global period rules also preclude reimbursement for any follow-up visits that take place subsequent to the procedure but within the GP.  These should be reported to Medicare with the modifier ‘GP’ to indicate that they took place but are not to be reimbursed. 

In the IR clinic, having the initial patient consultation with the physician at a time distinctly separate from the procedure itself will allow the billing of E&M codes in addition to the coding for the procedure.  Otherwise, a consultation on the same day as the procedure or on the day preceding the procedure will usually not be separately billable.

Examples of IR procedures that fall into the various Global Periods are as follows:

Determine the Level of Service

E & M services are comprised of seven components that go into determining the level of billing (Level 1 through Level 5).  It is imperative that the documentation in the medical record contains all of the components used to support the level of billing.  The determinant components include:

• History (Key Component)
• Examination (Key Component)
• Medical Decision Making (Key Component)
• Counseling
• Coordination of Care
• Nature of Presenting Problem
• Time

Most often the level of billing for IR consultations will be at the lower end of the spectrum.  The American College of Radiology’s ACR Radiology Coding Source contained this useful table in its January – February 2008 edition:

* Note that consultation codes (99241 - 99245 and 99251 - 99255) are not billable to Medicare, but may be used for commercial payers.  Substitute the appropriate Office Visit codes for Medicare billing.

For example, if a radiologist sees a patient at the request of the patient’s physician, for the purpose of providing a consultation to that physician concerning the patient’s suitability to undergo a therapeutic interventional procedure, an E&M service described by CPT code 99241 (or 99201 for Medicare) should document the following:

1. the physician referral for the consultation,
2. a problem-focused history,
3. a problem-focused examination, and
4. straightforward medical decision making.

The ACR notes “for E&M service provided that consist predominantly of time spent in counseling (more than 50 percent), the three-key-component requirement is waived in favor of the amount of time spent in the counseling encounter.”

Additional Considerations

The Centers for Medicare and Medicaid Services (CMS) provides an Evaluation and Management Services Guide and a Global Surgery Booklet, both of which contain a wealth of detailed information on this topic.  It is imperative that the radiologist’s coding team be familiar with the rules and regulations surrounding the billing of E&M codes.  The practice should be sure they routinely receive the consultation or office visit reports in order to properly determine the correct billing, preferably via the usual billing interface.

Summary

Understanding the nuances of Evaluation and Management Service billing will allow IR providers to set up scheduling, documentation and reporting systems in a way that optimizes the ability to maximize revenue from patient interactions surrounding interventional procedures.

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