Do you smile when others moan about the minutiae of E/M coding? If you're smiling because you think radiology coders don't need to worry about how to unravel E/M's key components and special requirements, think again.
Radiology coders have traditionally been free from the intricacies of E/M coding, but with the rise of interven-tional procedures, "radiologists are certainly providing E/M services," says Jeff Fulkerson, BA, CPC, coding specialist at the Emory Clinic in Atlanta. He adds that many of the E/M services provided fall into the consultation category and therefore carry the possibility of more generous reimbursement.
CPT Codes defines a consultation as a "service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source." Office or other outpatient consultations are described in codes 99241-99245, while inpatient consultations comprise the 99251-99255 series. Follow-up inpatient consultations are coded with 99261-99263.
Fulkerson describes a common scenario in which an orthopedist who is considering vertebroplasty asks for a radiologic consultation. "The patient is having back pain and related problems, but the treating physician isn't sure if vertebroplasty would be appropriate treatment. She asks the radiologist to render a medical opinion." The radiologist then enters into the special realm of E/M service known as consultation.
Because consultations are reimbursed at a higher rate than other types of E/M services (e.g., 99201-99205, Office or other outpatient visit, new patient; or 99211-99215, Office or other outpatient visit, established patient), coding requirements are more stringent.
Document the Key Components
Every E/M service including consultations requires physicians to document their efforts in three specific areas, says Judy Taylor, RHIT, CPC, a health-care consultant for CBiz MHM Business Services, a CPA firm in Kansas City, Mo.:
You will determine the level of code to assign by reviewing the complexity of the history, exam and medical decision-making (MDM) that the radiologist performs. For example, CPT 99242 requires an expanded problem-focused history and examination, with straightforward MDM. But 99244 requires a comprehensive history, a comprehensive examination and moderate-complexity MDM. Because 99244 is more in-depth, physician work relative value units (RVUs) are 2.58 compared to 1.29 for code 99242.
To code a specific level of service, the radiologist must meet specific documentation guidelines (DG), Taylor says. "For instance, to qualify as a comprehensive history, the physician must have covered each of three categories within history-taking: an extended history of present illness, a complete review of systems (ROS), and a complete personal, family and social [...]