A radiology practice that includes interventional procedures has to be up to date on the use of documentation and coding techniques for Evaluation and Management (E&M) services. Since these CPT codes in the 99xxx range are less commonly utilized in many radiology practices, identifying circumstances where E&M services are billable, and then properly documenting and coding for them, will require a collaborative effort between interventional radiologists (IR) and their coding team.
A patient’s visit with the IR prior to a procedure can variously be considered a consultation, an office visit, or a non-billable component part of the procedure depending on the circumstances. The first step is to determine if a visit is separately billable and then if it is, what are the proper documentation and coding requirements.
Check if the Service is Separately Billable
The initial visit might be considered by Medicare and other payers to be a component part of the surgical procedure. The rules that define payment for E&M services use a concept called the Global Surgery Package. The global period (GP) begins on the day of the procedure (or on a preceding day in the case of a 90-day GP) and, depending on the CPT code for the procedure, could run for 0, 10, or 90 days following the procedure.
Generally, E&M visits for the purpose of deciding whether or not to perform a procedure are billable and payable if they occur outside of the GP. During the GP, all services related to the procedure are included as a component part of the surgical package and therefore are not separately reimbursable. However, for a procedure with a 90-day GP, considered to be a ‘major surgery,’ an E&M service performed on the same day or preceding day for the purpose of deciding whether to perform the procedure may be separately reported and payable with the addition of Modifier-57 (Decision for Surgery).
In the IR clinic, scheduling the patient’s initial visit with the physician at a time distinctly separate from the procedure itself will allow the billing of E&M codes in addition to the coding for the procedure. Thus, for a 0- or 10-day GP procedure, the initial visit should be no later than the day prior to the procedure and for a 90-day GP procedure, it should be at least two days prior to the scheduled procedure unless it fits into the exception described above. Otherwise, a consultation on the same day as the procedure or on the day preceding the procedure will usually not be separately billable.
Check the Level of Service
When an E&M visit is separately billable, determining the level of coding depends first on where the service takes place. Beginning in 2021, hospital outpatient and office procedures will be determined either by the level of medical decision-making or by the total time spent on the patient’s case on the date of service. Prior to 2021, the level of service was determined by using a seven-level evaluation of components, but today the system is much simpler. Note that the rules for hospital inpatient and emergency department services have not yet changed.
The following table outlines the current criteria for each level of outpatient coding:
Level of Medical Decision Making
|Total Time Spent||Code||Total Time Spent||Code|
|Straightforward||15 – 29 minutes||99202||10 – 19 minutes||99212|
|Low||30 – 44 minutes||99203||20 – 29 minutes||99213|
|Moderate||45 – 59 minutes||99204||30 – 39 minutes||99214|
|High||60 – 74 minutes||99205||40 – 54 minutes||99215|
Consultations vs. Office Visits
A visit with the IR to determine the propriety of an interventional procedure is often referred to as a ‘consultation,’ but the term has a very specific definition and set of requirements in the context of coding and billing. A ‘consultation’ is defined as a service that: Requires an opinion or advice regarding the evaluation and management of a specific problem and Is requested by another physician or other appropriate source. A consultation initiated by a patient or family member, but not requested by a physician, may not be reported using consultation codes but rather will be reported using the office visit codes.
When they are available for use, consultation codes in the range 99241-99245 normally carry a higher reimbursement than office visit codes for the same level of service, but they also require some additional work. The request for consultation, the consultant’s opinion, and any services that are ordered or performed must all be documented in the patient’s medical record and communicated by a written report to the requesting physician.
Consultation codes are not recognized by Medicare or by certain other payers such as United Healthcare. For those payers, the appropriate regular office visit codes are used even if the tasks of additional documentation and sending a separate written report are performed. Note, however, that under the new time-based rules for E&M visits the time to document and create a separate report is added to the overall visit time and perhaps this could lead to a higher level of coding and reimbursement.
E&M billing for interventional radiology requires medical billing experts who have a good understanding of payer-specific reimbursement policies and billing guidelines. Finding and retaining such medical billing experts could be a challenging task. In such cases, you can outsource your medical billing and coding functions to Medical Billers and Coders (MBC).
Our interventional radiology billing services include charge entry, payment posting, denial management, IR coding, accounts receivables, provider enrollment, and credentialing. To know more about interventional radiology billing and coding services, contact us at firstname.lastname@example.org/ 888-357-3226.