Radiology Coding Alert

Radiology practices may be overlooking an opportunity to receive reimbursement for visits to hospital patients with abscess drainage tubes. To receive the full amount to which your practice is entitled, interventional radiologists must correctly document each visit.

Often, an interventional radiologist will be asked to place a tube to drain an abscess at the request of another physician, says Lisa Grimes, radiology special procedures technologist and reimbursement specialist for The University of Texas/Houston, Health Science Center. The existence of an abscess may have been discovered because the patient is exhibiting signs of an infection after a procedure, for example. If a drainage tube is placed, professional protocol calls for the radiologist to follow up with that patient, to make sure there are no complications and to assess the situation.

Zero Global Means Billable Follow-up

All percutaneous drainage tube procedures carry zero global surgical days, which means services performed during follow-up care would not be included in the fee for the placement. Grimes adds, the interventionalist will often make these hospital visits without expecting compensation. Thats good patient care, but not necessarily good business, she notes. Physicians legitimately have the opportunity to charge for this service.

In order to do so, however, the interventional radiologist must document each follow-up visit thoroughly, and include an assessment of the patients status and descriptions of services performed.

For instance, the interventionalist may examine the site of the drainage tube and note any improvement in the level of infection. His or her comments should be clearly stated in the patients medical record.

According to CPT 1999, subsequent hospital care following the placement of a drainage tube is a reimbursable service, providing specific requirements are met and the visits are adequately documented. CPT Codes states that all levels of subsequent hospital care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patients status (i.e., changes in history, physical condition and response to management), since the last assessment by the physician.

Editors note: CPT 2000 indicates no changes or revisions to these codes.

Subsequent Hospital Care

One of three levels of coding may be assigned, depending on the complexity of the service performed and the amount of time spent by the interventional radiologist. One code may be assigned each day the radiologist makes a legitimate follow-up visit.

Level I: CPT 99231 is most often and most appropriately assigned for routine care following placement of an abscess drainage tube. According to Grimes, code 99231 describes care of patients who are stable, recovering or improving.

Generally speaking, a radiologist will spend 15 minutes with a patient or on the unit when they assign 99231, she says. Any decisions for future care will most likely be straightforward and simple.

To assign a level I evaluation and management code, CPT also requires that at least two of three key components be present:

1. a problem-focused interval history

2. a problem-focused examination

3. medical decision-making that is straightforward or of low complexity.

Level II: Code 99232 is used to reflect a higher level of supervision. This code can be assigned to patients when they have developed a relatively minor complication or if they have not been responding as expected to previous treatment, says Grimes. The problems being addressed are more significant and the care provided is more complex.

These visits demand greater time spent at the patients bedside and in consultation with the patient and his or her family, she adds. CPT guidelines indicate that, to justify a level II evaluation and management charge, the physician will spend 25 minutes caring for the patient.

Level III: Code 99233, is seldom assigned for abscess drainage tube care, Grimes says, and can be justified only when the most serious problems arise. CPT requires that at least two of the following three key components are present when code 99233 is used:

1. a detailed interval history

2. a detailed examination

3. a medical decision-making of high complexity

A radiologist will spend 35 minutes or more with the patient under these circumstances, Grimes points out. Usually, these patients are unstable, have developed a critical complication or are displaying signs of a significant new problem.