Radiology Coding Alert

Question: Can I charge an E/M code for a radiologist for a regular office consultation regarding vertebroplasty?


Massachusetts Subscriber

Answer: Radiologists can and do provide evaluation and management (E/M) services, especially when interventional services are involved, so under the right circumstances, you can legitimately code E/M for vertebroplasty consultations.

Example: Your radiologist performs an evaluation of a patient that includes services above and beyond the simple preoperative evaluation to assess a patient for vertebroplasty, an image-guided therapy used to strengthen a broken vertebra. The E/M service might include reviewing the history, performing a physical exam, and determining which of multiple potential treatment options is most appropriate for the patient referred for consultation. Note: Simply obtaining informed consent and briefly reviewing the risk factors is not considered an E/M service.

What to do: Report the appropriate E/M code from the 99241-99245 range (Office consultation for a new or established patient ...). OIG takes E/M coding very seriously, including it in its workplan for 2005, so pay careful attention to the three components in each code and match them to your documentation before you code.

Remember: A consultation is a request from one physician to another physician for opinion or advice. If there is no specific request, there is no consultation.
 
According to the National Correct Coding Initiative, when radiologist interaction with a patient involves limited pertinent historical inquiry about reasons for the examination, allergies, getting informed consent, discussing follow-up, and medical record review, don't code an E/M. And if the medical decision-making is limited to whether to perform the procedure, whether comorbidities may impact the procedure, or whether a different procedure or approach would offer better information, you also shouldn't report a separate E/M.

What not to do: Don't report 76140 (Consultation on x-ray examination made elsewhere, written report) for this service. Report 76140 when another physician sends an imaging study to your physician for an opinion, and your physician reviews the films/images and completes a formal report with an interpretation.
 
Avoid reporting 76140 for radiological studies reviewed as part of an E/M service, because this review of imaging studies is part of the review of medical records included in the consultation. Reality: Medicare and many third-party payers refuse to reimburse for 76140, anyway.