Radiology Coding Alert

Extra work isn’t enough -- E/M rules still apply

Myth: You should never bill an E/M on the same claim as a diagnostic mammogram.

Reality: You can bill an E/M, but only if the radiologist performs work above and beyond that normally associated with pre- and postmammogram service work, says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management, in her audioconference for The Coding Institute, "Surefire Strategies for E/M Reimbursement in Your Radiology Practice" (available at http://www.audioeducator.com).

Preservice work typically includes a brief review of history and physical exam and obtaining informed consent, Buck says. Postservice work typically includes discussing findings and recommendations with the patient, she says.

Look for HEM in Documentation

Don’t miss: In addition to the extra work, the physician must meet the typical E/M documentation guidelines, Buck says.

You must have documentation of history, exam and medical decision-making to bill a separate E/M, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, RCC, CodeRyte Inc. coding analyst and coding review teacher.

In other words, "the physician needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem-oriented E/M service," says Christina Neighbors, MA, CPC, a charge capture reconciliation specialist for Franciscan Health Systems in Tacoma, Wash.

Example: The radiologist performs an ordered mammogram (77055-77056) and ultrasound (76645) 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 (E/M). The patient accepts a recommendation for a needle biopsy at a later date.