By Melody W. Mulaik
Evaluation and management (E/M) guidelines have changed significantly the past couple of years, and this is appropriately challenging many radiology practices to re-evaluate their coding and billing practices.
Historically ensuring the performance and necessary time to document the required components for these services has been challenging for many practices so the return on investment was not always present to justify coding and billing, especially for inpatient services. In some practices, interventional radiologists not only provide requested treatments, but they also directly manage the care of certain patients. In these circumstances, it is often appropriate to bill for an E/M service.
The specific changes for 2023 were focused on services provided in the hospital, patients that are inpatient or observation status. At a high level, the major changes made by the American Medical Association (AMA) most directly impacting interventional radiologists include the following:
- Inpatient and observation services were combined into one code set;
- Only the choice to use time or medical decision making (MDM) in determination of the code level;
- Revised time values assigned to the code levels;
- Inclusion of all the time spent on the date of the visit; and
- Eliminating the ability to use the history and exam or time in combination with the MDM to select the final code level.
While it is easier to meet the requirements of billing for an E/M visit for an inpatient, procedure global periods cannot be overlooked. Medicare’s global surgery policies are found in the Medicare Claims Processing Manual, Chapter 12, Section 40 (“Surgeons and Global Surgery”) and in the National Correct Coding Initiative Policy Manual for Medicare Services (NCCI Manual), Chapter I. Under these policies, the physician’s payment for a procedure includes payment for related E/M services during a specific period of time, known as the global period.
The table below shows Medicare’s global period categories. You can determine which category a procedure belongs to by looking up the CPT®/HCPCS code using the Physician Fee Schedule Look-Up tool on the CMS website.
Most interventional procedures are listed with an indicator of “000”, “010” or “XXX.”
A minor procedure is one that has a zero-day or a 10-day global period. Regarding E/M services on the same day as a minor procedure, the NCCI Manual states:
“In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”
The NCCI Manual also provides the example of a patient who is being seen for a head laceration. The physician who repairs the laceration should also not report an E/M code if the interaction with the patient involves simply checking allergy and immunization status and obtaining informed consent. However, the physician can report an E/M code with modifier 25 if he or she performs a “medically reasonable and necessary full neurological examination” in addition to the wound repair.
If a true interventional consultation is ordered, and not just a request for a specific procedure, the encounter at which the physician makes the decision to perform the procedure is separately billable if there is supporting documentation and medical necessity. For example, if the interventionalist sees the patient in consultation and recommends that a procedure be performed, the initial encounter should be separately paid even if it occurs on the day prior to the procedure or the day of the procedure. Appropriate modifiers will need to be applied.
It is important that every radiology group carefully review orders, documentation templates, physician workflows and billing processes to ensure the systems are in place to bill confidently and compliantly. The recent coding updates should encourage every practice to re-evaluate their opportunities to bill for these services and potentially increase revenue opportunities.
