Radiology Coding Alert

HCFA has announced the suspension of certain national Correct Coding Initiative (CCI) edits that were implemented during the fourth quarter of 2000. These CCI Edits bundled 66 evaluation and management (E/M) codes with more than 800 diagnostic tests and procedural services that carry no global surgical period (XXX global days). In total, more than 57,000 edits had been announced 27,000 of which pertained to radiology codes.

When the edits were put into place Oct. 30, 2000, HCFA stipulated that an E/M service would be payable on the same day as the bundled procedures only if it was significant and separately identifiable. Coders were required to append the E/M service with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when submitting the claim.

However, most radiology practices rarely report E/M codes because diagnostic radiologists usually provide only radiology interpretation services, not E/M services, points out Jean Stoner, CPC, manager of coding operations at CodeRyte, an Internet-enabled coding service and software provider based in Bethesda, Md. Therefore, despite the overwhelming number of edits relating to radiology, HCFAs fourth-quarter policy shift had minimal impact on Radiology Coding .

HCFA has provided no official reason for its subsequent decision to suspend these fourth-quarter edits. However, radiology coding experts believe the agency is responding to physicians and coders who have reported a large increase in denials when they bill E/M services with select interventional, neurological and pain-management codes. These services reflect those occasions when radiologists may perform consultations followed by or related to an interventional diagnostic procedure and/or treatment.

HCFA has not closed the door on reintroducing the suspended edits, but has made clear its intention to educate physicians and carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service.

Edits Were Intended to Prevent Double-dipping

HCFAs apparent determination to pay only for E/M services deemed significant and separate is due, at least in part, to chronic double-dipping by some physicians when diagnostic tests are performed, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. In fact, when it introduced the edits, HCFA stated they were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.

Although HCFA now says that any denied claims involving E/M services and diagnostic tests after Oct. 30 should be resubmitted, it recommends that radiology coders continue to attach modifier -25 to the E/M service when refiling the claim. In other words, radiologists must demonstrate in the patients medical record that the E/M service was significant and separately identifiable.

Presumably, it will be necessary to append modifier -25 to an E/M service when diagnostic test interpretations are also coded and billed, at least through calendar year 2001. For example, an interventional radiologist may be asked to conduct a consultation to determine if a patient is a candidate for vertebroplasty. During the visit, the radiologist might order computerized axial tomography of the lumbar spine (72131, 72132 or 72133). If the study is conducted and interpreted on the same day as the consultation, the radiologist may bill for both the CT and the E/M service. In situations like these, HCFA continues to recommend that coders append the consultation code with the -25 modifier and remember that an E/M service must meet all of the established criteria in order to assign the consultation CPT codes.