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BackTable / VI / Article
E&M Codes Every Interventional Radiologist Should Know
Lauren Fang • Updated Jun 5, 2021 • 1.9k hits
Different evaluation and management (E&M) codes are used depending on the type of work done and where it takes place, whether in the ER, ICU, or the outpatient setting. Interventional radiologist Dr. Ryan Trojan demystifies some aspects of E&M coding including global billing periods, modifier 25, and the scenarios in which these apply. He also describes some common inpatient billing codes.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• A global billing period is the number of days after a procedure where a physician cannot bill for inpatient progress notes. For IRs, there are really no procedures with 90-day globals, except carotid stent placement or endarterectomy, which most IRs are not performing. However, IRs do perform some procedures with 10-day globals. These include vertebroplasty/kyphoplasty, enteric access, venous access, cholecystostomy tube placement, and any ablation procedure. Aside from these five interventional procedures, IRs can bill for progress notes during the post-op period.
• Modifier 25, when appended to a service, allows an IR to receive payment for E&M the same day that a procedure or minor surgery is completed. However, the E&M services performed must be significant and separately identifiable from what would typically be done in the IR department. Dr. Trojan has successfully used Modifier 25 code, or -25, on critically ill patients, stroke patients, and septic patients.
• If E&M services are performed by an IR in the ER or ICU, different billing codes apply. E&M done in the ER could be billed under five different ER codes, and no time component is considered. However, for E&M in the ICU, critical care time can be billed.
• There are many different hospital inpatient billing codes that IRs can take advantage of, including admission H&Ps that are hospital day one codes, inpatient follow-up codes, as well as inpatient consult codes. Dr. Trojan will bill for 99222, which he uses when seeing a very straightforward hospital patient for the first time, even if he isn’t the admitting provider. Patients seen during followup, when inpatient progress notes are written, are billed using 99232. The 99232 code makes up at least 70% of Dr. Trojan’s total billing. Inpatient consult codes include 99251 through 99255. While an IR may commonly bill using codes 99253 or 99254, Medicare does not like to reimburse for these. However, Dr. Trojan states that even if a 99253 or 99254 is not accepted, the code can always fall back to 99222.
Table of Contents
(1) Global Billing Periods
(2) Modifier 25
(3) ER and ICU E&M Billing
(4) Inpatient Billing Codes
Global Billing Periods
A global billing period is the number of days after a procedure where a physician cannot bill for inpatient progress notes because post-operative follow up care has already been bundled into a global surgery fee. Five types of interventional procedures have 10-day globals and these are kyphoplasty, gastric access, venous access, cholecystostomy tube placement, and any ablation. Aside from these five procedures, IRs can bill for progress notes during the post-op period.
[Ryan Trojan]
...For IR, there are no 90-day globals. There's 10-day globals for five things: kyphoplasty, any ablation, gastric access, venous access and cholecystostomy tubes. Every other procedure you can bill postoperative day one for a progress note.
[Chris Beck]
Will you just take one step back and tell people what is a global billing period, and then follow up and just tell everyone why?
[Ryan Trojan]
Global billing period is the number of days after a procedure where you cannot bill for inpatient progress notes. So, let's say I do a cryoablation on a kidney. I'll see that patient the next day in the hospital. I can't bill for that because it's within the 10-day global. It's all bundled. The reason interventional radiology doesn't have any global periods is they dropped the payment for most of our procedures a couple of years ago, and then in order to do that, they got rid of the globals. So, I think you'll see in the future they will go after most of the surgical codes and then to appease the surgical societies, they'll drop the globals. My twin brother is a urologist. If you take a 90-day global surgery for him and you make it as your day global but you dropped the overall RVU payment, he'll make up for it on the backend by billing for those progress notes. So, again, despite those five procedures, which were kyphoplasty, gastric access, venous access, cholecystostomy tube placement and ablations, you can bill for followup. Now, my practice, no matter what the procedure is, even if it's kyphoplasty, it's in a 10-day global. I'll still round on those patients and the notes look the exact same, it's just that's when I'm not going to get paid for.
[Chris Beck]
...If I hear you correctly, we don't really have to worry about the 90-day global, unless maybe you're doing carotid endarterectomies, right?
[Ryan Trojan]
Correct. Carotid stents or endarterectomy, which most IRs aren't doing.
[Chris Beck]
Sure. Then for the 10-day global, which is a 10-day period in which you cannot bill after the procedure, cholecystostomy is on there, but biliary drain is okay, right?
[Ryan Trojan]
Correct, because they dropped the payment for biliary drains, not cholecystostomy.
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Modifier 25
Modifier 25 is used to append to a service and receive payment for E&M the same day that a procedure or minor surgery is completed. However, the E&M services performed must be significant and separately identifiable from what is typically done in the IR department. Dr. Trojan uses the Modifier 25 code on critically ill patients, stroke patients, and septic patients.
[Chris Beck]
One of the other things I wanted to demystify was a modifier 25 or dash 25. Will you elaborate for the uninitiated exactly what that is and then also what you do about it?
[Ryan Trojan]
So, modifier 25 is a modifier you append to a service if you want to get paid for E&M the same day that you do the procedure, so the same day you do the minor surgery. It's pretty simple. The actual terminology is it's used to facilitate billing of E&M services on the day of the procedure and must be significant and separately identifiable. Let's say I have a septic nephrostomy tube. I go see that patient in the ICU. I'll dictate in my note the significance of why the patient was seen on the floor, [for example] to evaluate if they could tolerate moderate sedation, do we need anesthesia. I'll go through a list of the things I'm looking at. Then when they come down to the department, I'll put my normal pre-procedure note. So, by documenting the significance of why I've gone up there, I hit that. Then, by having a separate pre-procedure note, then there's two different notes, so it's obviously separate from what I would normally do for a nephrostomy tube placement.
[Chris Beck]
Okay. The reason we're talking about this modifier 25 is if you were just to put in a regular note, say you decided not to see the patient in the ICU, but you're going to just see him right in the department before they rolled into the cath lab, that's a red flag or not a red flag. But, that's just a situation in which you can't bill for a separate history and physical apart from your procedure, right?
[Ryan Trojan]
Correct. You hit on a good point in that the first sentence of the note will say, "Patient was seen and evaluated in the ICU," so they know it's separate from the IR department.
[Chris Beck]
Okay. I know there's this one situation that's a little bit peculiar with the modifier 25 that you just can't see the patients in your department. You have to be on the floor, and yet, that has to be clear in the note. Are there any other sticky little points like that that may prohibit or restrict you from capturing an H&P code or an E&M code before the procedure on a same-day procedure?
[Ryan Trojan]
So, I try to use this code on critically ill patients, strokes, septic patients. I think it will get sticky if you try to do it on everybody, obviously, because there's no indication, but I think if you see the patients separate from your department, it will go through. I talked to my billers last week. One of the things that I constantly hear from the older generation is you don't get paid for E&M work, which is absolutely not true. So, my payment rate is about 99% for E&M work.
[Chris Beck]
Wow... Can you give us some good examples of procedures where you do go see the patient ahead of time, like on a same-day procedure, you said a septic nephrostomy tube. If I had to extrapolate, probably a cholecystostomy tube. Something that would be out of bounds would be a paracentesis or central venous access, something like that?
[Ryan Trojan]
Correct. The way I look at it is if someone calls me at 1:00 in the morning to do this on-call, then that fits the bill, right? Strokes, people who are bleeding to death, stuff of that nature, but, yeah, we don't typically do any routine stuff like ports or lines. We're currently not seeing those patients.
ER and ICU E&M Billing
Billing and coding can differ based on where E&M services are performed, such as in the ER or ICU. IR work done in the ER could be billed under five different ER codes, and no time component is considered. In the ICU, critical care time can be billed.
[Chris Beck]
There were some specific clinical scenarios I wanted to ask you about, and that was, does your billing and coding change depending on where the patient is? I think there's some specific billing and coding options for patients who are in the emergency room and the ICU setting. Will you just talk a bit for someone who's starting to want to push their practice to the next level as far as capturing some codes that are a little bit more on the margins in those scenarios?
[Ryan Trojan]
Yes. So, the ER has its own set of codes. It's five different codes and uses all the same data points that we've been talking about. There's no time component. Let's say somebody's G-tube falls out, I'm on-call, and I don't want to mess with taking them down to the IR lab, so I'll go see that patient in the ER. I'll swap out the tube at bedside, get a radiograph, and then patient goes home. Patient never gets admitted. So, in that case, I would have to bill an ER code. Otherwise, if a patient is in the ER, I evaluate them in the ER and they get admitted to the ICU, then I can bill ICU codes. If they get admitted to the floor, then I'd obviously bill the other codes.
[Chris Beck]
Okay. So, there's some specific codes for patients who are in the ER and the care is taking place in the ER, and there's some specific codes for your ICU patients.
[Ryan Trojan]
Correct. ICU patients, the critical care, you'll see in all your intensivists' notes they say, "X amount of time spent providing critical care time." So, if I have a stroke patient, let's say they got TPA, and they're shipped in. I go evaluate them, decide they're not a EVT candidate, but they have to go to the neuro ICU for critical care support because they got TPA. That's a patient where I could bill critical care time. I just document that on my note, "Patient is critically ill. They have a large vessel occlusion. Evaluated for EVT candidacy. Wanting to see if they could protect their airway from moderate sedation versus general anesthesia," et cetera, and just document that stuff in your notes. Again, I've had no problems when I document correctly getting this stuff through the billers and just getting it approved.
Inpatient Billing Codes
Admission H&Ps are hospital day one codes which have three levels. Dr. Trojan typically bills a level two, or 99222, if asked to see a very straightforward case on hospital day one. You can use the 99222 code even if you are not the admitting provider. For example, ten providers that are of different specialties can all bill 99222 on a patient. While one of those providers will be earmarked as the admitting or attending provider, this doesn't change reimbursement for the other physicians. Hospital day one refers to the first day the IR is going to evaluate the patient in the hospital, even if that patient has stayed in the hospital for several days up until that point. Patients seen during followup, when inpatient progress notes are written, are billed using 99232. The 99232 code makes up at least 70% of Dr. Trojan’s total billing. Inpatient consult codes to know include 99251 through 99255. The most common consult codes that an IR will use are 99253 or 99254. However, these inpatient consult codes can sometimes be tricky to bill with, as Medicare does not like to reimburse for these codes. However, Dr. Trojan states that even if a 99253 or 99254 is not accepted, the code can always fall back to 99222.
[Chris Beck]
Now, I want to talk about some of the inpatient codes. What are the most common codes that you use because you mentioned that you're doing a lot of inpatient billing?
[Ryan Trojan]
It's the same codes over and over again. So, admission H&P are hospital day one codes. They're on three levels. I typically bill level two. So, if I see a patient, that's 99222. Somebody asks me to do something that's very straightforward, then I'll bill a 99222, and then every patient that I see is a 99232 for followups. So, inpatient progress notes are 99232. That's probably at least 70% of my total billing. A routine clinical scenario would be an abcess drain. So, put an abscess drain in a patient, then I'm going to follow drain outputs while they're in the hospital. I'm going to talk to the patient, let them know what I expect for follow up, "I'm going to see you for an abscessogram in one to two weeks." I actually teach them how to flush their own drain. If they're of low income, which is not uncommon, I will provide them drain care supplies. So, all of my patients who have a procedure by me go home with a sack of flushes. I can tell you working with partners who sometimes maybe don't round on their patients, it's very common for patients to call and say, "Oh, my tube is not draining," and they come to find out they haven't been flushing it for the past two weeks."
[Chris Beck]
Going back to the admission H&P code, 99222, is that a code that has to only happen on day one of their admission or it's like they've been in house for a while, they're an ICU patient, all of a sudden they need a cholecystostomy tube? Can you use that code for midpoint of their hospital stay?
[Ryan Trojan]
Yes, 100%. So, that's the first time that I see them in the hospital. Ten different providers that are of different specialties could bill that same code on that patient. One of those providers will be earmarked as the admitting or attending provider, but it doesn't change reimbursement or any of that or documentation.
[Chris Beck]
Got you. Let me ask you this, this scenario, and it's a little bit nuanced. So, you see a patient for a cholecystostomy tube. You do the cholecystostomy tube. Now, you're following up, and then they become septic because of an obstructing stone or whatever, and then you get consulted for a nephrostomy tube. Does that patient still fall into your progress note kind of thing or do they fall back into another admission H&P?
[Ryan Trojan]
That would still be in your progress note because they're established patients.
[Chris Beck]
Exactly. So, now, they're an established patient, and they're just falling under your progress. Okay. So, I think covering the inpatient is the easiest thing to do, but there are some scenarios that I think are worth some specific attention. I think we've tackled if you're just trying to get into E&M coding, the two codes that you mentioned are the most important ones, your progress note and then your admission one, right?
[Ryan Trojan]
Yes. Again, just to clarify, on the admission H&P, that's just hospital day one. So, you don't have to be the admitting provider to bill that code. I think that's a big place of confusion for most IRs as far as they'll say, "Well, I can't bill that because I'm not the admitting provider," but that's just a hospital day one code.
[Chris Beck]
Well, but even if it's not hospital day one, can you bill that code?
[Ryan Trojan]
Yes. It's your hospital day one. So, a patient can be on hospital day 32, but it's hospital day one, and then everything else is a subsequent day.
[Chris Beck]
Okay. Got you. So, it's just the first day you're coming on to the scene.
[Ryan Trojan]
Then another thing that we're probably about to get into is the inpatient consult codes. So, 99251 through 99255. The most common codes that an IR will look at in that category is 99253, which is a level three or 99254, which is a level four. There are unique situations where I will bill those. If I get consulted and I go up and I see a patient, and we talk for 50 or 60 minutes, and we talk about doing the procedure or not doing the procedure, then I will bill that as a consult, and I will document in my note, "We consulted, here are all the treatment options. Patient likes to go with an IR procedure." Now, if they call me for a cholecystostomy tube in a nonoperative candidate that's septic, in my opinion, that's not really consult because there's no other options besides death. So, I always tell people that that's the fourth option. So, then I will just bill that as a 99222. So, work RVUs for a 99222, which is a level two hospital day one code, is 2.61. For a level three consult, it's 2.27. For a level four consult, it's 3.29. So, oftentimes, I'm billing 99222 just because it's easier. Trying to figure out if something is a consult or not can be complex, but my thoughts on the whole deal are is if you try to talk to a patient how to do their procedure, then that's a consult. Otherwise, if it's obvious that you're going to do the procedure, that's not really consult. So, kyphoplasty, for example, I always try to talk to ... I mean, I do a lot of kyphoplasty. I think it's a great procedure, but sometimes when I see the patient in the hospital, I'll play devil's advocate and talk about this conservative therapy, and then I'll let them guide me to say, "No, I want the intervention." So, that would be an example of somebody I would consult on because conservative therapy in the setting of a compression fracture is a viable option.
[Chris Beck]
It was my understanding that inpatient consult codes were a little bit more difficult to get reimbursed for. I didn't think Medicare actually reimbursed for this consult code. I thought it was a situation where you have to know where your payer is, which to me adds another layer of complexity to it, but I'll let you speak to it.
[Ryan Trojan]
Again, you're absolutely right. Medicare does not want to pay for these. So, when I document my stuff, the billers know that if my level four inpatient consult gets kicked back, then it just goes back to a 99222. So, that's the trick. That's always your fallback if they say no.
Podcast Contributors
Dr. Ryan Trojan
Dr. Ryan Trojan as a practicing Interventional Radiologist with Integris Health in Oklahoma City.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2021, March 19). Ep. 116 – Evaluation & Management (E&M) Coding 101 [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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