As interventional radiology continues to evolve into a true clinical practice, more time will be spent on the clinical decision process; this time is reimbursable in the form of evaluation and management (E&M) services. Once assumed to be an inherent part of the procedure itself, we know many procedures now do not include follow-up E&M components. Unfortunately, E&M coding is somewhat complex and requires rigorous documentation. Below is a discussion of the fundamentals of E&M services, general principles of documentation, and the mechanics of coverage and reimbursement.
Keywords: Coding, interventional procedures, evaluation and management, E&M
In their role as consulting providers or specialty care physicians for many patients, interventional radiologists have been providing additional services in the form of clinical evaluation and management (E&M) services. These services have historically been thought of as an inherent part of the procedure. However, as many procedures do not include follow-up E&M components, these services are themselves reimbursable but only if properly documented and coded. The complex nature of E&M coding and the documentation requirements have made many practices reluctant to bill for the legitimate services they provide. However, by not billing for these services, they are losing revenue.
Interventionalists are assuming increasing clinical responsibilities. A recent Society of Interventional Radiology survey estimates that the average interventionalist spends 6% of his time providing such services. In addition, introduction of new Current Procedural Terminology. 4th Edition (CPT) codes has resulted in a significant reduction in reimbursement for some percutaneous procedures, such as transjugular portosystemic shunt (TIPS). With the new codes, a 0-day global period has been assigned with the intention of separating reimbursement for the procedure itself from reimbursement for patient evaluation and management. To recoup potentially lost revenue for services provided, practices providing clinical management services need to bill for them.
This article will address the fundamentals of E&M services, general principles of documentation, the approach to code and document E&M services, and the basic mechanics of coverage and reimbursement.
The discussion of coding services is based upon guidelines provided in the CPT manual, published by the American Medical Association (AMA), and documentation guidelines provided by Medicare billing as published by the Centers for Medicare and
Medicaid Services (CMS). However, each payer may have its own billing and documentation requirements.
These documentation guidelines for use with E&M codes were developed by CMS and the AMA in 1994 and were updated in 1997. However, due to delayed implementation of the 1997 update, auditors have been instructed to use either the 1995 or 1997 guidelines when reviewing medical records, whichever is the most beneficial to the provider. These guidelines can be found at the CMS website at: http://www.cms.hhs.gov/medlearn/emdoc.asp.
Note that although E&M services provided by physicians and nonphysician providers (NPPs) do not vary with regard to documentation guidelines, levels of service or types of service, Medicare reimbursement, when provided by NPPs, is reduced to 85%. For other third-party payers, there may be no difference in reimbursement.
THE CODING ENVIRONMENT
Medicare, Medicaid, and other third-party payers use CPT codes to evaluate use of health care services and determine provider reimbursement. CPT codes constitute level I of the Centers for Medicare and Medicaid Services' Common Procedural Coding System (HCPCS). CPT coding translates physician procedures/services into five-digit codes. To receive correct payment for their services, physicians must submit claim forms with correctly assigned CPT and HCPCS codes, supported by diagnostic codes from the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM).
Clinical services are reimbursed based upon the relative value unit (RVU) weighting of the appropriate CPT code. With changes in the RVUs of some of the procedures commonly performed by interventionalists and with the removal of clinical evaluation and management from the RVUs for these procedures, it is appropriate for radiologists to bill separately for these clinical services. In fact, it is the only method by which the interventionalist will be reimbursed appropriately for this care.
Codes for E&M services are service-specific but not specialty- or provider-specific. However, there are very specific rules and circumstances that determine whether an interventionalist may bill E&M services (e.g. the global surgical package, unbundling, and the amount of documentation contained in the medical record).
ELEMENTS OF E&M CODES
As shown in Table Table1, 1. the E&M categories represent the type of services rendered, and the subcategories define the services or circumstances more specifically.