Radiology Coding Alert

Traditionally, Radiology Coders have had fewer opportunities to assign evaluation and management (E/M) codes than those in other specialties. There are, however, more circumstances when these codes accurately reflect the level of care provided. When service warrants reporting these codes, radiology practices are able to receive payment for time and effort over and above what is included in procedure codes. Radiologists and coders who overlook this opportunity forfeit a significant amount of reimbursement.

In most cases, E/M codes are associated with interventional, neurological and pain-control procedures. Among the services where E/M codes might be reported in addition to the procedural and radiological supervision and interpretation (RS&I) codes are percutaneous abscess drainage, angioplasty and intravascular stenting, uterine fibroid embolization, vertebroplasty and embolisms.

We are seeing more E/M codes associated with radiology in these areas, notes Jean Stoner, CPC, radiology coding specialist and manager for coding operations at CodeRyte, an Internet-enabled coding service and software provider based in Bethesda, Md. Radiologists and coders need to be aware of circumstances where assigning E/M codes is appropriate so they can collect the reimbursement to which they are entitled.

Two Key Points Validate E/M Coding

When considering whether to assign an E/M code, however, radiology coders must exercise caution. There are two key areas that can help a coder determine if an E/M code is justified, Stoner says. The first involves understanding the difference between a request for consultation and a referral from another doctor. The second entails being aware of what services are considered part of the procedural package.

When a primary-care physician or other specialist sends a patient to a radiologist, it may be considered either a referral or a request for consultation, Stoner explains. If the referring physician has already determined what procedure is to be conducted, like an injection for pain management, the patient is considered to be a referral. The radiologist performs the service and simply codes the procedure and the appropriate RS&I code.

In other cases, however, the primary-care physician may send the patient to the radiologist for a consultation requesting that the radiologist review the patients history, perform an examination, provide an assessment and recommend a plan for treatment. The radiologist may also provide the treatment, sometimes on the same day as the consultation.

This would be a time when the radiologist may report an E/M service in addition to the procedure, she says. The treatment was not planned before the radiologist sees the patient, and the referring physician isnt saying simply do this to the radiologist. The doctor isnt sure how to approach treatment and asks the radiologist for an evaluation, as well as giving approval to proceed as appropriate.

Consultation Must Be Well Documented

According to Cheryl Schad, BA, CPCM, CPC, owner of Schad Medical Management, a billing and coding consulting firm in Woodbury, N.J., consultations must be well documented to justify assigning an E/M code. The referring physician must provide a written or verbal request for a consultation, and the radiologist must provide a written report to that doctor. In addition, the radiologist should make a note in the patients chart that he or she was asked to provide the consultation.

If the E/M service is provided on the same day as the treatment, Schad says, coders should append a modifier. In some cases, the -57 modifier (decision for surgery) would be used, although generally it is added to the E/M code only if the surgery is considered major (90-day global period). This communicates to the carrier that the initial decision to perform the procedure was made during the consultation visit, she says. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) may be more appropriate for procedures without global periods.

Coders should note, however, that various insurers might have different rules concerning what is included in the global package, both in terms of preoperative decisions and follow-up care. Medicare rules are standardized, but other payers may establish diverse guidelines. Always check with the patients insurance carrier to determine requirements that will affect coding and reimbursement.

Although the workup on a consult may be considered an E/M service, this generally is not the case when a patient has been referred for a predetermined procedure. Yes, the radiologist will examine the patient before beginning any procedure, Stoner admits. But the Health Care Financing Administrations Medicare Carriers Manual clearly states that preoperative visits after the treatment decision is made are considered components of the procedural package. Therefore, the work that in other instances might be considered an E/M service should not be billed separately.

When it is apparent that a radiologist may legitimately report a consultation code, coders would choose from one of five codes in the office or other outpatient consultations section of the CPT manual (99241-99245), depending on the level of care provided. If the patient has been admitted to the hospital and the consultation is provided in that setting, radiology coders would choose from the initial inpatient consultations series (99251-99225).