To be clear, I am a strong advocate for interventional radiologists appropriately billing for evaluation and management (E/M) services.Technically the E/M visit codes are available for use by all specialties but everyone must be mindful that all criteria of the code family must be met, the medical record documentation must support the billed level and type of service and the medical necessity for the visit must be clear. As radiologists continue to seek new streams of revenue, this goal must be balanced against compliant coding and billing practices.
This column will focus on two types of visits that interventionalists may question whether or not it is appropriate to bill with the short answer being “probably not.” Practices should do a complete evaluation of all available authoritative guidance when making decisions regarding the appropriateness of billing for these services and not rely solely on this high-level overview. There are additional E/M visits/services that may also be in question and the same level of cautious approach should be applied.
Critical Care (99291-99292)
First, we will discuss critical care. The Centers for Medicare & Medicaid Services (CMS) has stated that “Providing medical care to a critically ill patient should not be automatically deemed to be a critical care service for the sole research that the patient is critically ill or injured.”
The medical necessity to support critical care services must be clear and evident regarding the actual management of the patient at the bedside. Medicare claims data from 2022 reflects the top 5 specialties billing CPT® 99291 were emergency medicine, pulmonary disease, critical care (intensivist), internal medicine and nurse practitioner. Neither interventional radiology nor vascular surgery even made the list of specialties who provided these services. It would be highly unusual and an outlier in the data for an IR to bill for codes 99291 and 99292 routinely or with any frequency.
Inappropriate billing of critical care services has been a focus of the Office of Inspector General (OIG) who has conducted multiple reviews related to these services and the risk they present to CMS. The OIG notes the documentation of the critical care services is provided through the progress notes which document the total time spent dedicated to the patient on the date of encounter. This is time spent in direct care of the patient, it could also be spent in the time to assess the status of the patient, the results of tests and discuss with staff on the floor about the patient. During this time, the physician is solely focused on this patient, immediately available, and providing care to no other patient.
Overwhelming the interventional radiologist (IR) may assess medical records, tests, converse with staff to understand the status of the patient, they are not providing medical services at the bedside for this critically ill patient. They are making the determination to provide a separate intervention, within a dedicated angio or other type of dedicated suite for which they will separately bill their services.
The Society of Interventional Radiology (SIR) has a practice resource that references critical care1 and CMS provides examples for review that reinforces that it takes more than a critically ill to qualify for these services.2 Lastly, the American Medical Association (AMA) within their CPT® Assistant, March 2022 publication also addresses critical care services.
If you are considering billing for critical care, review all of the authoritative guidance and resources to ensure compliance.
Complexity Add-On Code (G2211)
CMS created a new HCPCS code (+G2211 – Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition) to account for complexity of services provided to new and established patients. CMS indicated they believe the updated definitions for CPT® 99202-99215 reflect the work provided in a “typical” office outpatient visit; however, for some specialties they do not adequately capture the resources associated with patient care. CMS indicated code G2211 is intended to be used for services that are part of ongoing care to better account for the inherent complexity for all needed health care services and/or ongoing care related to a patient’s single, serious or complex condition. CMS emphasized the add-on code is not based on the characteristics of a particular patient, but rather the relationship between the patient and practitioner.
The underlined words are key. In order to add G2211 there must be ongoing care of the patient’s complex condition. Seeing the patient in consultation or even performing a procedure and having a follow-up visit does not justify ongoing complex care.
The first part of the add-on code, “continuing focal point for all needed health care services” describes a relationship between the patient and the practitioner, when the practitioner is the continuing focal point for all health care services the patient needs which is not a typical scenario for an interventional radiologist. The second part of the add-on code, “medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition” describes the relationship between the practitioner and patient for a specific type of condition(s). Unlike the first part of the code, described above, this part of the code is specific to a serious condition or a complex condition. The “ongoing care” describes the longitudinal relationship between the practitioner and patient but in reference to a single, serious or complex condition. CMS provides the example of a patient with HIV who has an office visit with their infectious disease physician, as part of their ongoing care. Since the infectious disease physician is part of ongoing care and will have to weigh the same factors as the primary care physician in the above example during regularly scheduled visits, the E/M becomes more complex in nature due to the compound building of decisions and considerations for the patient. Even though the infectious disease doctor may not be the focal point for all services, HIV is a single, serious and/or complex condition. If the relationship between the infectious disease physician and patient is ongoing, G2211 could be billed.
So, could an interventionalist bill +G2211? Maybe but highly unlikely unless their practice patterns are very unique.
References
https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/practice-resources/globallsurgery-icn907166.pdf
Medicare Claims Processing Manual, Chapter 12, Section 30.6.12 (Rev. 2997, 07-25-2014)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2997CP.pdf
