Radiology Coding Alert

Question: A radiologist in our practice recently performed an arteriogram, and the patient remained under observation for five hours before being released. Before the procedure, the radiologist documented a history and physical and, afterward, monitored the patient. How should I code these extra services?

New York Subscriber

Answer: E/M services are often overlooked as appropriately billable services. The service described in the question appears to be part of the normal postprocedure care and would not be separately coded. But there may be situations when the service is unplanned and/or an evaluation of the patient is required to determine whether the procedure is required. In these cases, it may be appropriate to assign an observation code (99234-99236) for the service. It is strongly suggested that interventional physicians and the billing staff become familiar with the E/M codes and their appropriate application in the interventional and radiological arenas.

Reader Questions were answered and reviewed by Donna Richmond, RCC, CPC, radiology coding specialist with Acadiana Computer Systems Inc., a medical billing management company based in Lafayette, La., that serves more than 200 radiologists, pathologists and anesthesiologists.