ACR Radiology Coding Source™ January-February 2008

While radiation oncology and nuclear medicine practices commonly report evaluation and management (E&M) services, many diagnostic radiologists, practice managers, and coders find themselves questioning whether this is an area to develop or to ignore.

The vast majority of E&M services in diagnostic radiology occur within the area of interventional procedures. These E&M services can be identified, documented, coded, and billed. Without a system in place to do this, interventional radiologists are providing separately identifiable services at no charge to patients, and the opportunity to consistently apply correct coding for all services performed is being overlooked.

To begin, you should familiarize yourself with the main categories of E&M services to determine the categories into which the interventional radiologist’s services will fall. These will be in the areas of hospital inpatients or outpatients and office locations (CPT code sections 99201 through 99215 and 99221 through 99233). To these E&M CPT code categories, add the section on consultations, which can occur in any service location (E&M code sections 99241 through 99255).

By narrowing the focus of coding selection to these areas, you can learn how to determine whether the services have been provided, whether they can appropriately be reported, and what is required for documentation of the services rendered.

Type of E&M Services

For the purpose of determining what E&M services have been provided, it must be remembered that these services, as defined in CPT, are face-to-face encounters between physician and patient. E&M services performed by interventional radiologists include the consultation, which involves providing information about treatment options for a patient at the request of another physician. E&M services provided also can be categorized under the hospital inpatient and outpatient hospital or office care areas. These services can be provided to either new or established patients, and can include visits resulting in a decision to perform an interventional procedure, visits to follow up and check patient status after an interventional procedure, or visits consisting of a majority of the encounter time spent in counseling. All of these constitute E&M services, but not all may be separately identifiable services. Many types of E&M services are considered to be included in primary procedures and are not separately reported.

E&M Services Appropriate for Billing

Not all E&M services provided with some relationship to interventional surgical procedures may be appropriately billed. The CPT book contains information at the beginning of the surgical section that defines the surgical package, listing all types of services that are included and, therefore, are not billed separately. Of note, this information states that subsequent to the decision to perform the surgery, one related E&M service provided either the day before or the day of the surgery is included in the surgical package.

A second area where E&M services may not be appropriate to bill relates to the global period concept, established by the Centers for Medicare & Medicaid Services (CMS). These global period designations may be found on the Medicare Physicians’ Fee Schedule, where surgical procedure codes are assigned a designator of “000,” “010,” “090,” “XXX,” YYY,” or “ZZZ.” The designations “000,” “010,” and “090” indicate that there are zero (surgical period is only the day of the procedure), 10, or 90 days during which all services related to the surgical procedure are considered to be included in this global surgical package. The global period concept does not apply to “XXX” procedures. The global period for “YYY” procedures is defined by the carrier, and the global period for “ZZZ” procedures, which are linked to related procedures, is defined by the related procedure. 

An E&M service may be separately reportable on the same date of service as a procedure with a global period of “000,” “010,” or “090” only under limited circumstances.¹ The Correct Coding Initiative (CCI), Version 13.1, states that for surgical procedures with a global period of 90 days (major surgical procedures), an E&M service performed on the same day as the surgical procedure, for the purpose of deciding whether to perform the surgical procedure, may be separately reported with modifier -57 (Decision for surgery). In this same introductory section of CCI, we find another instruction for surgical procedures with a global period of 10 days (minor surgical procedures). For these, an E&M service performed for the purpose of deciding whether to perform the procedure is not separately reported, as this is included in the payment for minor surgical procedures. However, any separately identifiable E&M service, unrelated to the minor surgical procedure, may be reported with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). As well, any separately identifiable E&M service, not related to any surgical procedure, may be appropriately reported with modifier -25 during any postoperative day period.

Examples of procedures with a global period of 90 days include biliary catheter placements, cholecystostomy, central venous access device declotting, inferior vena cava (IVC) filter placement, and intraperitoneal permanent catheter placements. Examples of those with a 10-day global period include G- and J-tube placements, central venous access device placements and removals, pancreas biopsy, temporary intraperitoneal catheter removal, and radiofrequency ablation (RFA) of the liver. The zero-day global procedure list is lengthy, and includes breast biopsies, urinary tube placements, thrombolytic infusion, vascular embolization, angioplasty, vascular stenting, most biopsies, thoracentesis and paracentesis, abscess drainages, uterine fibroid embolization, transjugular intrahepatic portosystemic shunt(TIPS), atherectomy, mechanical thrombectomy, spinal injections, and intraperitoneal temporary catheter placement.

Procedures to which the global concept does not apply include most invasive diagnostic studies and most vascular catheter placements.

Documentation Requirements for E&M Services

Documentation may be in any written form. It can be, and most often is, a handwritten note in a patient chart, as long as it is legible. Requirements concerning the content of this documentation have been established by CMS in the 1997 Documentation Guidelines for Evaluation and Management Services,* and can be downloaded from the CMS Web page . These guidelines instruct the physician about the three key elements of the E&M service. They are

1. History
2. Examination
3. Medical Decision Making.

*Per Medicare guidelines, carriers may continue to review claims using both the 1995 and 1997 Documentation Guidelines for E&M Services (whichever is more advantageous to the physician) until further notice.

These three key components form the basis for selection of the CPT code (level) for the E&M service. All three key components are required to be documented for all new patients, whereas only two of three key elements are required to be documented for any established patient. Furthermore, for E&M services provided that consist predominantly of time spent in counseling (more than 50 percent), the three-key-component requirement is waived in favor of the amount of time spent in the counseling encounter. There is also an additional documentation requirement for an E&M consultation, which states that the request for consultation from another physician must be documented. This must not be simply a referral to transfer care of the patient to the radiologist, but must be a request from the patient’s physician for information to assist that physician in decision making about the patient’s treatment. If the radiologist assumes the care of the patient at the consultation encounter, the E&M service becomes a new or established office/outpatient or new or subsequent inpatient encounter instead.²

For each of the three key E&M elements, there is a further breakdown of the documentation requirements among levels of service described as problem-focused, expanded problem-focused, detailed, and comprehensive. The CMS 1997 Documentation Guidelines provide definitions, specific facts, and examination details necessary for documentation of each level of service. These details are separately listed for each of the three E&M key elements. Although the documentation requirements may at first seem quite confusing and representative of an immense amount of information to be learned, most E&M services provided by radiologists will be at the lower or lowest levels. Documentation requirements for these levels are less stringent and should present no difficulty for the radiologist. It is recommended, however, that radiologists read and understand all of the documentation requirements before beginning to identify, document, and bill for E&M services.

One other factor in documentation of E&M procedures is time spent providing a level of service. Although this is not a key element, it is an important element to document for several reasons. CPT discusses intraservice time in connection with E&M services in detail. Summarizing that discussion, intraservice time is defined as face-to-face time with the patient for outpatient consultation and counseling E&M services. For inpatient care, intraservice time is defined as the total of face-to-face time with the patient, as well as the time the radiologist spends establishing and reviewing the patient chart, writing notes, and communicating with other professionals and the patient’s family. Even though time is not one of the key elements used to select the level of E&M care, it does serve as a guideline.

CPT Codes for E&M Services Commonly Provided by Radiologists

The following is a table that lists the most common E&M services that may be identified and appropriately billed by interventional radiologists³:

For example, if a radiologist sees a patient at the request of the patient’s physician, for the purpose of providing a consultation to that physician concerning the patient’s suitability to undergo a therapeutic interventional procedure, an E&M service described by CPT code 99241 should document the following: (1) the physician referral for the consultation, (2) a problem-focused history, (3) a problem-focused examination, and (3) straightforward medical decision making.

E&M documentation, coding, and billing should be a collaborative effort between the radiologist and the coder. Knowledge of appropriate E&M coding rules, uses of modifiers, global surgery days, and the global surgical package will be needed by the coder. The radiologist will have the knowledge necessary to document history, examination, and medical decision making, according to the CMS 1995 or 1997 guidelines publication. When the radiologist and the coder each contribute their unique skills to this collaboration, E&M coding will become a reality for interventional

¹ CCI, Ver. 13.3, Introductory Section

² CPT 2008, American Medical Association.

³ Table data from CPT, 2008 E/M Pocket Reference Guide, American Medical Association