Radiology Coding Alert

Do you smile when others moan about the minutiae of E/M coding? If you're smiling because you think radiology coders don't need to worry about how to unravel E/M's key components and special requirements, think again.

Radiology coders have traditionally been free from the intricacies of E/M coding, but with the rise of interven-tional procedures, "radiologists are certainly providing E/M services," says Jeff Fulkerson, BA, CPC, coding specialist at the Emory Clinic in Atlanta. He adds that many of the E/M services provided fall into the consultation category and therefore carry the possibility of more generous reimbursement.

CPT Codes defines a consultation as a "service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source." Office or other outpatient consultations are described in codes 99241-99245, while inpatient consultations comprise the 99251-99255 series. Follow-up inpatient consultations are coded with 99261-99263.

Fulkerson describes a common scenario in which an orthopedist who is considering vertebroplasty asks for a radiologic consultation. "The patient is having back pain and related problems, but the treating physician isn't sure if vertebroplasty would be appropriate treatment. She asks the radiologist to render a medical opinion." The radiologist then enters into the special realm of E/M service known as consultation.

Because consultations are reimbursed at a higher rate than other types of E/M services (e.g., 99201-99205, Office or other outpatient visit, new patient; or 99211-99215, Office or other outpatient visit, established patient), coding requirements are more stringent.

Document the Key Components

Every E/M service including consultations requires physicians to document their efforts in three specific areas, says Judy Taylor, RHIT, CPC, a health-care consultant for CBiz MHM Business Services, a CPA firm in Kansas City, Mo.:

You will determine the level of code to assign by reviewing the complexity of the history, exam and medical decision-making (MDM) that the radiologist performs. For example, CPT 99242 requires an expanded problem-focused history and examination, with straightforward MDM. But 99244 requires a comprehensive history, a comprehensive examination and moderate-complexity MDM. Because 99244 is more in-depth, physician work relative value units (RVUs) are 2.58 compared to 1.29 for code 99242.

To code a specific level of service, the radiologist must meet specific documentation guidelines (DG), Taylor says. "For instance, to qualify as a comprehensive history, the physician must have covered each of three categories within history-taking: an extended history of present illness, a complete review of systems (ROS), and a complete personal, family and social history (PFSH)."

Similar guidelines exist for the physical exam and MDM components. "Physical exams for a radiologist are probably very specific to the problem being assessed, so they might be less complex than those a primary-care physician would provide," Taylor says. The radiologist might examine only the affected area (e.g., the spinal column), the constitutional system (respiration, vital signs, etc.) and psychological status (e.g., mood).

For this reason, Fulkerson says, radiologic consultations are often level-one or level-two services, e.g., 99241, 99242.

MDM is the hardest component to discern accurately, Taylor adds. Documentation guidelines for history and exam are quantifiable if "x" number of elements are reviewed, the service rank is easy to identify. For coders to determine accurately the level of MDM, "the physician must document all of the thoughts running through his or her head." Therein lies the rub, Taylor says. "Physicians must document the information they review, what possibilities they consider and what possibilities they eliminate. All of this is mental and automatic, so doctors must remember to write all this in the record."

MDM also includes the amount and type of data reviewed, and the risk of the management option(s) selected. There are a number of "score sheets" in use by insurance payers or offered for sale by organizations (such as MGMA) that quantify the key elements and assist with consistent coding of E&M services.

DGs for all three of the key components are required for initial consultations, Fulkerson says. Follow-up consultations offer some slight respite, with only two of the three components required.

"Three R's"Govern Consultations

Besides making sure a patient record meets the DGs for the three key components, you must also ensure special requirements have been satisfied.