Internal Medicine Coding Alert

Question: If the internist orders an x-ray and provides personal, independent visualization of the image, how many points should I add to the E/M level?

Florida Subscriber

Answer: You can add points to an E/M level based on elements of medical decision-making during the visit as long as the physician doesn't also submit a bill for x-ray interpretation.

For example, your internist orders an x-ray (71010, Radiologic examination, chest; single view, frontal). That means your physician can add one point to the E/M service for ordering a radiological test in CPT's radiology section. If the physician reviews the report on the next visit, he can receive one point for reviewing the radiological test. And, when the internist personally views x-ray films, the physician can add two points to the E/M's medical decision-making.

 - Answers for You Be the Coder and Reader Questions were provided by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.