A radiology practice with interventional radiology (IR) must stay current with documentation and coding for evaluation and management (E&M) services. The first step in medical billing for radiologists is determining whether the service can be billed separately, then identifying the proper documentation and coding requirements.
Key Takeaways
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E&M improved to include Medical Decision Making (MDM) and time-based coding options in 2021.
- Guidelines expanded in 2023 to include all other service categories relevant to IR.
- Global surgery periods are a bundled time frame, including 0-, 10- or 90-day spans.
- Electronic health records (EHRs) now contain relevant templates for IR documentation.
- E&M services can ensure all professional services are properly captured and reimbursed.
How the E&M Framework for IR Has Evolved
In the past, the E&M framework primarily relied on detailed patient history and physical exams. An attempt to simplify documentation for office and outpatient visits began in 2021 with the introduction of Medical Decision Making (MDM). Evaluation and management coding for interventional radiology can now determine the appropriate code based on the complexity of the MDM or the total time spent on the patient encounter.
These guidelines were then expanded again in 2023 to include all other service categories relevant to IR, including hospital and emergency department visits. Specifically for IR, this mean understanding when E&M services can be billed separately from the procedure, carefully tracking time or documenting complex MDM.
Navigating Global Surgery Periods in IR Coding
Global surgery periods in IR coding and billing refers to a bundled time frame surrounding a surgical procedure, typically, 0, 10 or 90 days. During the this period, the payment for the surgery covers all routine care related to the procedure, including pre-operative visits, the surgery and post-operative follow-ups.
Explicit documentation supporting separate billing must clearly show the medical necessity for the E&M service. It may also be necessary to note that the E&M service was distinct and separate from the decision to perform the procedure.
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Interventional Radiology - Examples |
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90-day Global Surgery Package |
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10-day Global Surgery Package |
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0-day Global Surgery Package |
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Technology and Auditing for Compliant E&M Billing
Today's modern technology is essential to improve E&M coding accuracy and efficiency, such as configuring EHR systems with templates for IR documentation. These templates can prioritize support for either time-based or MDM coding.
Regular auditing is crucial for ensuring compliance and maximizing appropriate revenue. This structure can include internal and external audits for a fresh perspective on compliance risks and revenue opportunities.
The Financial Impact of Accurate E&M Coding
E&M services can contribute to overall practice revenue. It ensures that all legitimate professional services and properly captured and reimbursed, including patient assessment, decision-making and care coordination.
Summary
Understanding the nuances of Evaluation and Management Service billing will allow the IR practice to set up its scheduling, documentation, and reporting systems in a way that optimizes their ability to maximize the revenue from patient interactions surrounding interventional procedures.
Partner With HAP Today
Healthcare Administrative Partners (HAP) is your partner in E&M billing and coding for IR. Since 1995, HAP has grown to provide renowned hospital-based practices with flexible, unrivaled revenue cycle management solutions.
Ready to get started with expert interventional radiology reimbursement services? Contact HAP to begin your partnership today.
[i] Current Procedural Terminology is a copyrighted code set developed and maintained by the American Medical Association, and CPT is a registered trademark.
Erin Stephens, CPC, CIRCC is the Sr. Client Manager, Education at Healthcare Administrative Partners.
This article was updated on April 28, 2021.
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