Radiology Coding Alert

You can’t report these together every time, but in some cases you should.

Radiology coders don’t frequently code E/M claims, and in many cases, they might shy away from these services since radiologists infrequently see patients face-to-face for evaluation and management visits. But just because you don’t bill them often doesn’t mean you should ignore E/M codes in every case. Sometimes, you are warranted in reporting an E/M code with a mammogram, as long as the radiologist’s documentation supports the charge.

You can bill an E/M in cases when the radiologist performs work above and beyond that normally associated with pre- and post-mammogram service work. Pre-service work typically includes a brief review of history and physical exam and obtaining informed consent. Post-service work typically includes discussing findings and recommendations with the patient.

The American College of Radiology addresses this issue on its website with the following advice: “It is only appropriate to bill for a consultation or other evaluation and management (E/M) service when the service is provided and documented according to established E/M guidelines,” the ACR advises. “For breast interventional procedures, a brief review of history and physical exam and obtaining informed consent is not a separately reportable E/M service. This service is considered bundled into the surgical procedure code.” (Read the ACR’s advice at https://www.acr.org/FAQs/Medicare-Regulation-FAQs-Mammography).

The key part of the ACR’s advice is the line that states, “When the service is provided and documented according to established E/M guidelines.” Since many radiology coders aren’t familiar with the intricacies of E/M coding, now is a good time to nail those down.

Look for HEM in Documentation

You must have documentation of history, exam and medical decision-making (MDM) to bill a separate E/M service, and those three elements together are often known as “HEM.” The Correct Coding Initiative does not bundle G0202 (Screening mammography, bilateral [2-view study of each breast], including computer-aided detection [CAD] when performed) G0204 (Diagnostic mammography, including computer-aided detection [CAD] when performed; bilateral) and G0206 (Diagnostic mammography, including computer-aided detection [CAD] when performed; unilateral) into the E/M codes or vice-versa, so as long as you document the E/M elements, you can report the service.

According to the E/M and CPT^® guidelines, you must meet two of the three elements (history, exam, MDM) to bill a particular E/M level for an established patient, but if you see a new patient, you must meet all three elements.

Example: The radiologist performs an ordered mammogram and ultrasound for a possible mass. The findings for both are suspicious for malignancy. The radiologist takes a history, performs a limited physical examination and discusses the diagnosis and management options with the patient. The patient accepts a recommendation for a needle biopsy at a later date. You’ll report the appropriate E/M code based on the complete documentation and the elements of history, exam, and MDM. Here’s a quick rundown of what those each mean.

History

The radiologist should include in the encounter notes the necessary elements of history, which are History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and Social History (PFSH).

Obtaining the patient’s chief complaint and HPI is an important first step in determining the etiology of a patient’s problem. The HPI information can assist a practitioner in arriving at the patient’s diagnosis, Terri Orcala of Orcala Billing in Kansas City, Mo., tells Radiology Coding Alert.

For instance:  A brief HPI, in which your clinician records only one to three elements, can support 99213, but you may be able to report a higher level code if your clinician documents an extended HPI with four or more elements, she says.

Code 99213 requires one to three HPI elements and 99214 requires four or more if the history is going to be counted toward the service level. Similarly, when reporting PFSH, if your clinician does not note any changes in the PFSH or at least make a note stating, “PFSH not changed from previous visit,” you might end up having to bill a lower level code than appropriate.

Your E/M code choice also depends on the ROS component. The clinician should review the number of systems applicable to the current condition. If billing 99213, the ROS must include at least one system. When billing 99214 and the history is one of the two key components used toward the service level, at least two systems must be reviewed, Orcala says.

Exam

Your physician must also document which “organ systems” he checks on physical exam, and specifically which “bullets” he checks within the organ system, based on the 1997 E/M guidelines. For instance, “examination of thyroid” is a bullet point under the “neck” organ system in the E/M guidelines.

Choose one:  You should assign the level of physical exam based on the following criteria:

• Problem Focused — One to five bullets from one or more organ systems
• Expanded Problem Focused — At least six bullets from any organ system
• Detailed — At least two bullets from six organ systems OR 12 bullets from two or more organ systems
• Comprehensive — Two bullets from EACH of nine organ systems

MDM

When considering the Medical Decision Making (MDM) component of the E/M service, you should check the documentation to find these elements:

• Number of diagnoses and management options
• Amount and/or complexity of the data reviewed
• Risk of complications and/or morbidity or mortality.

These elements will help you understand the level of the MDM and the E/M code that it supports. Medical decision-making reflects the intensity of the cognitive labor performed by the physician. The official rules for interpreting the MDM are identical for both the 1995 and 1997 E/M guidelines. The elements of MDM will also help in identifying the severity of the patient’s problem (e.g. self-limited/minor, low, moderate or high), which may also help in assessing the level of E/M code to report for the encounter.

Is Time on Your Side?

Alternate method: Rather than basing your E/M code selection on HEM, you can code based on time if more than 50 percent of the encounter was spent on counseling and/or coordination of care. To do so, your clinician’s note must document the total time, the time spent counseling the patient, and a description of the counseling and coordination of care. Coding based on time may allow you to report a higher level E/M code.

For instance: Your surgeon documents an office visit for an established patient that earns 99213 based on HEM, but the note also documents that 15 minutes of the 25-minute encounter was spent discussing test results and the patient’s prognosis following a procedure. Because more than 50 percent of the time was spent in coordination of care, you can code 99214 for the visit. You can find the typical times associated with each level of E/M visit in the CPT^® manual under each code’s descriptor.

Modifiers: Even though the CCI doesn’t bundle E/M visits with mammograms, most coders report that they have more payment success if they append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the problem-oriented office visit code to show that the physician performed two separate services. The diagnosis code for the E/M service should not be that of a general health examination, but should instead support the concern addressed during that portion of the visit.