HAP Radiology Billing and Coding Blog

Most of the annual changes to diagnosis coding under ICD-10^[i] system take effect on October 1, but other changes occur during the year. There are quite a few codes that became effective on January 1, 2021, all related to COVID-19 conditions.

Click here to read our 2025 code changes update article.

The big news in Current Procedural Terminology^[i] (CPT)^® revisions for 2021 is the overhaul of the Evaluation and Management (E&M) section, reducing documentation requirements, and introducing new rules for determining the level of coding. These changes will affect interventional radiologists and radiation oncologists more than they will the day-to-day work of diagnostic radiologists. First, we will review the other non-E&M code changes affecting diagnostic and interventional radiology for 2021.

Click here to read our 2025 code changes update article.

With the new year comes the annual revision of Current Procedural Terminology^[i] (CPT)^® coding that practices have to be aware of.  For diagnostic radiology, the changes for 2020 are relatively few and they are concentrated in the areas of abdominal and gastrointestinal plain films, nuclear medicine procedures for tumor localization, and myocardial PET imaging.  The changes to interventional radiology coding are likewise quite limited and involve pericardial and spinal puncture procedures. 

Our own Sandy Coffta, Vice President of Client Services, spoke with Aunt Minnie’s Brian Casey at the 2019 RSNA Annual Meeting in Chicago.  In the interview posted on auntminnie.com, Sandy mentioned some of the highlights that practices should be concerned about in the coming year. 

The 2020 annual update to the ICD-10-CM^[i] system used in medical insurance claim billing became effective on October 1, 2019.  Twenty-one (21) codes were deleted, thirty (30) codes were revised and 273 new codes were added.  The good news for radiologists is that relatively few of these changes will affect your work. 

Read our 2021 IR billing & coding article

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.

While certain procedures incorporate moderate sedation (also known as conscious sedation) into their treatment codes, according to modern CPT® guidelines, it is much more common to bill procedures and anesthetics separately. This enables greater specificity in billing regarding time spent and provider involvement. As a radiology practice, maintaining moderate sedation billing compliance is crucial to your financial wellness and practice reputation. Whether you are new to billing and coding or need a refresher, Healthcare Administrative Partners' expertise is here to help.

Understanding Moderate Sedation Coding for Radiology

Previous coding methodology allowed for billing in 15- and 30-minute increments and included code series 99143-99145 and 99148-99150. However, these features became obsolete in 2017. The new standard of radiology moderate sedation documentation includes codes 99151-99153 and 99155-99157, and is based on factors of:

• 15-minute intervals: Intraservice time must be recorded in minutes. You may report the initial 15-minute code once you document at least 10 minutes of intraservice time. Then, you may report each additional 15-minute add-on code once you have provided at least 8 minutes beyond the first 15 minutes.
• Physicians involved: The proper code will vary depending on whether the administering physician is the same physician performing the diagnostic or therapeutic service or a separate person.
• Patient age: There are separate codes for patients under 5 years of age and those 5 or older.

These tables should help you understand which codes apply to which services.

[On-site table 1 - Descriptors]

[On-site table 2 - Total intraservice time]

*Note that for Medicare, 99153 is a technical-only add-on code in facility settings. It is packaged into the facility payment and is not separately reimbursed to the physician — physicians are only paid for 99151 and 99152 codes.

How to Document Moderate Sedation Properly

With all this information in mind, every moderate sedation record should provide these key pieces of data:

• Patient age
• Physician(s) name(s)
• Physician or physician's clinical need for participation
• Intraservice time (total time in minutes and start/end time stamps)
• The term “moderate” or “conscious” sedation
• Any pre- or post-sedation monitoring and assessments
• Pre- and post-sedation work the physician performs

Here is an example of good documentation for moderate sedation:

Moderate intravenous conscious sedation was supervised by Dr. X. The patient was independently monitored by a Registered Nurse assigned to the Department of Radiology using automated blood pressure, EKG and pulse oximetry. The detailed Conscious Record is permanently stored in the Hospital Information System. The following is the conscious sedation record including Start and End times: MEDS GIVEN 4 MG VERSED AND 200 MCG FENTANYL; SED START 1503 END 1531, FOR 28 MINUTES.

Stay Informed and Supported at HAP USA

Proper coding allows radiology practices like yours to obtain the maximum reimbursement for the services you offer, promoting long-term financial integrity that allows you to continue serving patients in need. Healthcare Administrative Partners is dedicated to helping providers optimize their performance with expert revenue cycle management advice and solutions. Stay up to date on the latest industry news when you subscribe to our blog. Or, contact us directly to learn more about how we can actively support your operations.

Medicare publishes its rules and requirements for the coding and billing of medical procedures to obtain reimbursement under its programs, but many commercial insurers are not as transparent about their own requirements. This leaves medical billing professionals in the dark when there are new procedure codes or changes to existing coding in the American Medical Association’s CPT^® code set or by federal regulation.  Such is the case with mammography coding for 2017.  Below we have summarized the key coding considerations for radiology practices billing mammography services this year. (Click here to read our complete article on the 2017 coding changes impacting diagnostic and intervential radiology.)

Click here to read our 2024 code changes update article. 

The annual cycle of revising codes in the Current Procedural Terminology (CPT)® has been completed with the issuance of the Medicare Physician Fee Schedule (MPFS) Final Rule for 2017. For diagnostic radiology, the changes this year are in mammography bundling, ultrasound screening for abdominal aortic aneurysm, and fluoroscopic guidance.  Interventional Radiology (IR) will also be subject to bundling and other rearranging of codes for certain procedures.  Finally, there are new codes that have been created to describe procedures previously unlisted, which generally will improve reimbursement for those procedures, and codes deleted from use, which will return the affected procedures to the ‘unlisted’ category.

Our first article in this series provided a list of questions to ask when evaluating a professional services Revenue Cycle Management (RCM) vendor for your radiology practice.  If your current RCM vendor cannot answer all of them positively, it’s time to look for a new vendor.  With a large number of RCM companies available in the market, how should you decide which one to choose?