Radiology Coding Alert

You Must Perform Full E/M Visit

Remember that your E/M visit must be medically necessary and separately identifiable from the surgery, and that you must fulfill all of the "bullets" that CMS identifies in its E/M documentation guidelines before you report the E/M code. Simply seeing the patient to decide whether he or she requires surgery is usually not enough to warrant reporting an E/M code.

The National Correct Coding Initiative (NCCI) guidelines state, "When physician interaction 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 billed."

The NCCI Edits also states that if the medical decisionmaking that evolves from the procurement of the information from the patient "is limited to whether or not the procedure should be performed, whether comorbidities may impact the procedure, or if a different procedure or approach would render better information, an evaluation and management code is not billed separately."

Although Medicare follows NCCI guidelines, some private insurers have their own regulations regarding when you can separately report radiology E/M services, so be sure to check with private payers in your area before you report E/M services for preoperative patients.

Modifier -57 Demonstrates Decision

But what if the radiologist performs a consultation and then schedules surgery for the very next day? Because the global period begins on the day before surgery, many practices write off the consultation charge as a preoperative visit. These practices may be throwing away reimbursement. Because you made the decision for surgery during the consultation, you can separately report both the consultation and the surgery.

The Medicare Carriers Manual (MCM), section 15501.1, instructs carriers to "pay for an E/M service onthe day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 (Decision for surgery) to indicate that the service was for the decision to perform the procedure.

If you see a patient for a level-three outpatient consultation and you perform a transhepatic stent introduction and drainage catheter placement the very next day, you should report 99243-57, 47511 (Introduction of percutaneous transhepatic stent for
internal and external biliary drainage) and 75982 (Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation).

2. Determine the Surgical Global Period Dont append modifier -57 to all of your preoperative E/M codes just yet. The interventional radiology codes that carry XXX, zero- or 10-day global periods do not require it. Medicare restricts modifier -57 to major surgeries only, and MCM specifically instructs carriers not to pay for an evaluation and management service billed with the CPT modifier -57 if it was provided on or the day before a procedure with a zero- or 10-day global surgical period.

Note: See Global Periods XXX and 000 Are Not Synonymous article for more information on differentiating
between global periods.

If you administer a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero- or 10-day global periods, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code instead of modifier -57.

Avoid the Usual Modifiers

We often see patients to determine whether they are good candidates for uterine artery embolizations (37204, Transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method, noncentral nervous system, non-head or neck; and 75894, Transcatheter therapy, embolization, any method, radiological supervision and interpretation), says Dave Wiliford, coding supervisor at Radiology Associates in  Richmond, Va. "The radiologist discusses the surgery with the patient, and they schedule the procedure."

Because 37204 carries a global period of "0," you should avoid modifiers -57 and -25, even if the radiologist performs the consult on Monday and the embolization on Tuesday. Simply report the appropriate consultation or office visit (99201-99215) code on the E/M date and the embolization code on the surgery date, Rutigliano says.

3. Is the E/M Visit Unrelated to the Surgery

CPT and Medicare guidelines specify that all follow-up care related to the global surgical procedure is included in the global package and cannot be reported separately. But what happens if you discover a problem unrelated to the surgery?

Suppose the radiologist places an IVC filter into a patients inferior vena cava due to deep venous thrombosis. He reports 37620 (Interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular, intravascular [umbrella device]), which has a 90-day global period, and 75940 (Percutaneous placement of IVC filter, radiological supervision and interpretation).

When the patient presents to your practice two weeks after surgery, the radiologist notes excessive discharge from the patients left eye. She complains that her eye has itched for three days. The interventionalist examines the patient and diagnoses conjunctivitis (372.0x). He prescribes antibiotic eyedrops and  advises her to use cold compresses on the eye to reduce the swelling.

Because the conjunctivitis evaluation is unrelated to the IVC filter placement, you should append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code (99211-99215) and link it to the conjunctivitis ICD-9. Modifier -24 tells the payer that the E/M service is separately identifiable from the surgery.