HAP Radiology Billing and Coding Blog

The importance of accurate and complete coding cannot be overemphasized for any area of radiology, but the complexity of interventional radiology (IR) coding makes it even more critical for optimal reimbursement. The prerequisite for complete coding is thorough documentation that includes all of the required elements, along with a coding team that is highly trained in IR.

Complete documentation of any radiology procedure is the key to appropriate reimbursement. This is especially true for venous duplex Doppler ultrasound exams, where including fewer than the required number of elements for a complete procedure will result in reimbursement for a limited study.

Arterial catheter embolization is an interventional radiology procedure that requires detailed documentation of the steps performed by the physician to maximize coding and reimbursement. The procedure places medications, embolic agents, or a radiopharmaceutical into a blood vessel to prevent abnormal bleeding, close off vessels, eliminate abnormal connections between arteries and veins, or to treat aneurysms or tumors. Common embolization procedures include the treatment of uterine fibroids or the destruction of liver tumors using y-90 radioembolization.

The annual changes to the ICD-10-CM[i] coding system come in two forms. The Coding and Reporting Guidelines describe how the codes are to be used, and then there is the list of available codes themselves. 159 new codes became effective on October 1, 2021, and many codes have been revised or deleted. Not surprisingly there are a few revisions to the reporting of COVID-19 infections and related conditions.

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. 

We’ve been watching the development of the Appropriate Use Criteria/Clinical Decision Support (AUC/CDS) requirement since 2014 when it was first included in the Protecting Access to Medicare Act (PAMA 2014).  The latest Medicare Physician Fee Schedule (MPFS) confirms that the requirement to use CDS will begin this coming year on January 1, 2020, but imposition of any penalties associated with the referring physician’s failure to do so will be delayed until 2021.  We are currently in a voluntary reporting period that runs through the end of 2019, so it’s a good time for every radiology practice to review where it stands with regard to this important Medicare regulation.

In an article published in the online Journal of the American College of Radiology¹, authors from Duke University Medical Center Department of Radiology present a study conducted to demonstrate the variability and complexity of radiologists’ dictated notes. The authors chose to analyze the language used to describe normal thyroid glands in chest CT reports as a “surrogate for the broader readability of radiology reports”. In a sample of nearly seven thousand non-contrast chest CT reports, the researchers found 342 unique sentences or phrases describing a normal thyroid gland. Furthermore, linguistic analysis suggested that descriptors for a normal thyroid gland require an advanced college-level education for comprehension. This text is well above the national average health literacy level and results in reports that are difficult for patients to understand.²

In radiology, like all other medical specialties, proper documentation is critical to achieving appropriate reimbursement. If the proper terminology is no used or important descriptors are omitted from the radiology report, the physician may not get paid for the services he or she performed.

Radiologists are understandably nervous about the Medicare rule requiring the use of Appropriate Use Criteria and Clinical Decision Support (AUC/CDS) systems. 

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.