Radiology E/M Services: What to Bill and How to Code It
June 25, 2014
Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H
Laurie Desjardins, CPC-I
Agenda
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When is E/M appropriate for Radiology?
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Medicare global surgery rules
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Types of E/M services performed by radiologists
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Documenting E/M services
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Coding E/M services
When is E/M Appropriate?
Pre-Procedure Evaluation
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The payment for non-surgical and minor surgery interventional radiology procedures includes
routine pre-procedure evaluation of the patient
Medicare Policy
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“When physician interaction with a patient is necessary to accomplish a radiographic
procedure, typically occurring in invasive or interventional radiology, the interaction generally
involves limited pertinent historical inquiry about reasons for the examination, the presence of
allergies, acquisition of informed consent, discussion of follow-up, and the review of the
medical record. In this setting, a separate evaluation and management service is not
reported….
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As a rule, if the medical decision making that evolves from the procurement of the information
from the patient is limited to whether or not the procedure should be performed, whether
comorbidity may impact the procedure, or involves discussion and education with the patient,
an evaluation/ management code is not reported separately. If a significant, separately
identifiable service is rendered, involving taking a history, performing an exam, and making
medical decisions distinct from the procedure, the appropriate evaluation and management
service can be reported.”
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Medicare National Correct Coding Policy Manual for Carriers, Chapter 9
Separate E/M Service
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A pre-procedure E/M service can be charged when a significant, separately identifiable,
medically necessary service is performed and documented
Example #1
The radiologist is asked to see a trauma patient in consultation regarding injury to pelvic
vessels. The radiologist performs and documents a consultation, then performs transcatheter
embolization of an internal iliac branch.
Charge for an E/M service (992xx-25) as well as the embolization.
NOTE: A modifier 25 is commonly utilized when a significant, separately identifiable,
medically necessary E/M is perform on the same day as a minor procedure.
Example #2
Patient presents with clinical history of cystic breasts with nipple discharge. History and exam
are performed. Patient has a cyst aspiration today and is referred to a breast surgeon for
evaluation of surgical option of duct removal.
Bill for OP visit (9920X or 9921X). Mod 25 may be needed, depending on payor.
Example #3
A patient calls the radiology department and asks for an appointment re possible
vertebroplasty. He has read about the procedure and thinks it might help him. The radiologist
evaluates the patient and schedules the procedure for the following week.
Report an office/outpatient visit (9920X or 9921X). No modifier is necessary.
Medicare Global Surgery Policy
CPT – Global Surgical Package
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Pre-Operative Period
o Subsequent to decision for surgery E/M service on date immediately prior to or day of
surgery
Intraoperative Period
o Opening to close
Post-Operative Period
o Major = 90 days
o Minor = 0 or 10 days
Global Days
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Global periods for each category:
o Non-surgical procedure: No global period
o Minor surgery, zero-day: Only the day of the procedure
o Minor surgery, 10-day: Day of the procedure and the following 10 days
o Major surgery: The day before the procedure; the day of the procedure; and the
following 90 days
Major Surgeries (90 day) Examples
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TAA and AAA repair (eg, 33880, 34802)
Dialysis fistula declotting (36870)
Carotid artery stent (37215-37216)
IVC filter (37191)
Certain biliary procedures (eg, 47490, 47510, 47511, 47530, 47630, 47801)
Perc nephrostolithotomy (50080)
Intracranial PTA/stent (61630, 61635)
Major Surgery
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The encounter at which the decision is made to perform a major procedure is separately
billable, even if it falls within the global period
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Use modifier 57 (Decision for surgery)
Example
The radiologist sees an outpatient with a thrombosed AV fistula, performs history & exam. Fistula
declotting is performed later that day.
• Bill for an office/outpatient visit with modifier 57.
Types of E/M services performed by radiologists
Counseling and Coordinating Care
The Time Factor
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If more than 50% of the time (face-to-face time with the patient in the office or outpatient
setting or floor/unit time in the hospital) is for counseling or coordination of care then time
can be used as the determining factor for coding the service.
Counseling Example
A patient is diagnosed with a cerebral aneurysm and is referred to a neurointerventionalist for
evaluation for possible embolization. The neurointerventionalist sees the patient with his family for
the first time and discusses etiology, prognosis and treatment options. A total of 60 minutes is
spent face-to-face with the patient and his family, 45 minutes was spent in discuss and answering
questions. Surgery is scheduled for the following week.
Billable new patient visit based upon time. (99205)
Follow-up Visits
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Routine follow-up visits within the global period are bundled into the payment for the
procedure.
Medically necessary follow-up after the global period is separately payable.
o Non-surgical procedures: No global period.
Minor surgery: Global period is limited to the day of the procedure (000) or lasts for 10 days
after the procedure (010).
o Major surgery: Global period lasts for 90 days after the procedure.
Codes for Follow-Up
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Charge for inpatient follow-up visits using subsequent hospital care codes (99231-99233).
Charge for outpatient follow-up visits using office/outpatient visit codes (99211-99215).
F/U Example #1
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Hospital rounds on an inpatient who had percutaneous drainage of peritoneal abscess
yesterday
o 49021 has a 0-day global period
o Follow-up visit on the day after the procedure is separately billable
o Bill the visit as subsequent hospital care (99231-99233)
o No modifier is necessary
F/U Example #2
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Outpatient follow-up visit by a patient who underwent percutaneous vertebroplasty two weeks
earlier
o 22521 has a 10-day global period.
o Follow-up visit 14 days later is separately billable
o Bill the visit as an established patient office/outpatient visit (9921X)
o No modifier is necessary
F/U Example #3
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Outpatient follow-up visit by a patient who underwent carotid stent placement one month
earlier
o 37215 has a 90-day global period.
o Follow-up visit 30 days later is not separately billable
o Do not submit a charge for an E/M service on this encounter
“Incident To” Services
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Must be performed under the direct supervision of the physician
Direct supervision implies that the physician has seen the patient on a prior visit, has instituted
a plan of care, and remains involved in the patient’s care.
Does not apply to new patient visits or to established patient visits for new problems.
Additionally, the physician (or another physician who belongs to the same group practice)
must be present in the office suite at the time the NPP sees the patient.
F/U Example #4
The radiologist sees a patient in consultation regarding uterine fibroids. The patient subsequently
undergoes uterine artery embolization. Two weeks following the procedure the patient is seen in
follow-up by a physician assistant employed by the radiology group.
The visit occurs at the radiology group’s private office, and the radiologist is present in the office
suite, although he does not see the patient at this visit.
An established patient office visit (typically 99212-99213) is billed under the radiologist’s provider
number and is paid at 100% of the physician allowable.
New Patient/Consultation Visits
Medicare Consultations
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As of Jan 1, 2010, consults are no longer a covered service (except for telehealth services)
Per Medicare (CMS) “Physicians shall code patient evaluation and management visit with E/M
codes that represent where the visit occurs and that identify the complexity of the visit
performed”
Medicare Consults: Office/Outpatient Setting
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In the office or other outpatient setting where an evaluation is performed, providers shall use
the CPT codes (99201-99215) depending on the complexity of the visit and whether the
patient is a new or established patient to that provider
Medicare Consults: Inpatient Setting
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Inpatient setting - provider who performs initial visit will bill 99221-99223
Nursing facility provider who performs initial visit will bill 99304-99306
As a result of this change, multiple billings of initial hospital and nursing home visit codes may
occur even in a single day
Hospital and Observation Care
Initial Hospital Care
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Initial hospital care (99221-99223) is to be billed by the admitting physician of record and for
the initial visit by a physician asked to consult on the care of the patient.
If a patient is admitted to inpatient status by the radiologist following a procedure, the initial
inpatient care is included in the global payment for the procedure.
Hospital Discharge Management
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Hospital inpatient discharge day management (99238-99239) is to be billed only by the
patient’s attending physician.
If the radiologist is the attending physician, he or she can charge for discharge day
management provided that it does not fall within the global period of the procedure.
Code selected based on time
Hospital Discharge Example
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A patient is admitted to inpatient status by the interventional radiologist following a TIPS
procedure. The patient is discharged by the radiologist two days later.
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The TIPS procedure has a zero-day global period. Therefore, the radiologist can charge for
subsequent hospital care (99231-99233) on day #2 and hospital discharge (99238-99239)
on day #3.
Documenting E/M services: Level … WHAT?
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Understanding the term “Level”
o Last digit of the E/M CPT code = level
99201/99211 ... Level 1
99202/99212 ... Level 2
o Regardless of place of service
99221 ... Level 1 hospital admission
99233 … Level 3 subsequent hospital visit
E/M Key Components
History
Exam
Medical Decision making
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Counseling
• Coordination of Care
• Nature of Presenting Problem
• Time
E/M Documentation 101
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Each patient encounter should include:
o Reason for the encounter and relevant history; physical examination findings; and
prior diagnostic test results;
o Assessment, clinical impression or diagnosis;
o Plan for care, and
o Date and legible identity of the observer
Key Components
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E/M services are defined in CPT on the basis of the 3 key components:
o History
o Physical exam
o Medical decision-making
The higher the level of service (e.g., 99203 versus 99201), the more extensive is the required
documentation.
Reports of consultations and new patient outpatient visits must meet all three key components
indicated in the CPT manual.
Example: A Level 3 outpatient consult (99243) must have documentation of:
– A detailed history
– A detailed exam
– Medical decision-making of at least low complexity
Reports of established patient outpatient visits and subsequent hospital care must have at least
two of the three key components indicated in CPT.
Example: A report for Level 3 subsequent hospital care (99233) must have at least two of the
following:
o Detailed interval history
o Detailed examination
o Medical decision-making of high complexity
Documentation Guidelines
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The AMA’s Documentation Guidelines for Evaluation and Management Services provides
additional definitions needed to interpret the key component requirements in CPT
Either the 1995 or the 1997 Guidelines may be used
http://www.cms.hhs.gov/medlearn/emdoc.asp
Assessment and Plan
Medical Decision Making (MDM)
• What is the acuity of the problem(s)?
• What are the risks associated with the condition?
• What’s the complexity of the materials (labs, radiology, records, info from others) involved in
treating the problem?
Linking the Key Components
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Medical Decision Making = Medical Necessity
Medical Record must demonstrate
“… support (of) the intensity and frequency of the E/M service met but that it did not exceed
the patient’s clinical needs.”
‘…the patient’s present condition is the key factor in determining medical necessity.”
Coder’s Mantra
If it isn’t documented, it wasn’t done
Payer’s Mantra
Was it Medically Necessary?
Making MDM Intuitive
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Key Questions / Decision Points
– How many problems were assessed?
 Are they new? Is there enough info to create a care plan?
 Are they established? What is the current status?
– What are the risks of the problems to the patient?
– What data was reviewed?
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Document the data collected
Documenting Risk
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Document comorbidities, underlying diseases, or other factors that increase the complexity
Document performed or planned surgical procedures or invasive tests
– Procedures performed may require separate note
Document the evaluation of possible tests and treatments that may be contra-indicated by
chronic conditions (i.e. poor kidney function limits the use of any contrast)
Document if procedures or tests need to be done on an urgent basis
Documentation Reminders
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At least one assessment for each encounter
Document status of each existing problem(s) managed during this encounter
– Stable, unstable, worsening, at risk for …
For unclear diagnosis of new problem, can use “R/O”, “Probable”, or “Possible” (CAN
NEVER USE FOR BILLING Dx.)
Treatment should be documented including instructions, nursing, therapies, and meds
Document all ancillary tests ordered w/reason
Indicate who is being consulted and why
Tying MDM to Hx and Ex
Backing into History and Exam
History of Present Illness
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The patient’s chief complaint and history of present illness (HPI) must be documented by the
physician (not by the patient or nursing staff)
PFSH/ROS
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Past/family/social history (PFSH) and review of systems (ROS) may be recorded by the patient
or by ancillary staff.
The physician must review the patient’s responses with him or her.
The physician must write a note “supplementing or confirming” the information.
– “PFSH and ROS are as per patient questionnaire”
– “ROS is as per nursing history except patient also complains of . . .”
The physician may update the PFSH and ROS from an earlier visit, rather than recording the
entire thing again
– Review the information with the patient
– Document the DATE AND LOCATION of the information (e.g., “per my consult note
of
– July 19”)
– Document any new information, or document that the information is unchanged
– Example: “PFSH and ROS: As recorded in my consultation report of August 3, except
that patient is now experiencing leg pain at rest as well as with exercise.”
ROS
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Complete ROS requires review of at least 10 organ systems:
– The physician may list the findings for 10 separate organ systems; or—
– List the findings for those systems with positive or pertinent negative findings, and
indicate “all other systems were reviewed and negative”
If the note does not meet one of these criteria, the ROS will not be considered complete.
Comprehensive History
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Comprehensive history is required for Level 4 and 5 consults and Level 4 and 5 new patient
office/outpatient visits
Comprehensive history requires documentation of:
– Chief complaint
– Extended HPI (at least 4 attributes of the presenting problem)
– Complete ROS (review of at least 10 organ systems)
– Complete PFSH (at least 1 item from past history, 1 from family history, and 1 from
social history)
Physical Exam
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Per 1995 E/M guidelines:
– Problem-focused exam = limited exam of single body area or organ system
– Expanded problem-focused exam = limited exam of at least 2 body areas or organ
systems
– Detailed exam = extended exam of at least 2 body areas or organ systems
– Comprehensive exam = findings about 8 or more of the 12 organ systems
Comprehensive Exam
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A comprehensive exam is required for Level 4 and 5 outpatient and inpatient consults and
Level 4 and 5 new patient office visits.
Comprehensive exam requires documentation of findings about at least 8 organ systems (not
body areas)
– Document all positive and pertinent negative findings.
– Asymptomatic organ systems (i.e., organ systems unrelated to presenting problem)
with normal findings may be described simply as “normal”
Written Guidelines vs. Clinical Judgment
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Focused on the clinical care of the patient, define “detailed”
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CMS is not the only payer – avoid ‘magic words’
Documenting for care – or $$
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“Though an E/M service may code to a high level based on the documentation of key
component work, it is inappropriate when the patient’s effective management does not require
the code’s work.”
Medicare Contractor
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Question: Our office uses a template for office visits. Does Medicare prefer one type of
template to the others?
Answer: Medicare does not endorse any templates. … In reviewing medical records, a pattern
of template use sometimes has a “cloning” effect between patients. The patients’ medical
records tend to lose the patient-specific information. When using a template for
documentation, take care to note your findings in a patient-specific manner.
Avoid - “Magic Words”
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“Clinical Documentation Improvement” is more than key words needed for reimbursement
Document what and why
– Document the sequence of events
– Document the complications / side effects / progression of disease
Coding E/M services
Beyond the Levels of Service
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Category of Service
– New patient / Established patient
– Outpatient vs. Inpatient services
Who rendered the service
– Physician (MD/DO)
– Non-physician Practitioner (NP, PA)
– Role of the Resident
Beyond the Levels of Service (cont.)
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Who is the billing provider
– “Shared Visit”
– “Incident-to”
Procedure “Package”
New / Established Patient
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A new patient is one who has not received any professional services from the
physician/qualified health care professional or another physician/qualified health care
professional of the exact same specialty and subspecialty who belongs to the same group
practice, within the past three years.
– CPT codes 99201-99205
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An established patient is one who has received services within the past three years.
– CPT codes 99211 - 99215
Palmetto Weighs In
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Physicians in the same group practice who are in the same specialty must bill and be paid as
though they were a single physician.
– only one E/M service may be reported unless the E/M services are for unrelated
problems.
Documentation record could be used to explain why treatment was needed by a different
provider in the same group
Your Presenters