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BackTable / VI / Podcast / Transcript #116
Podcast Transcript: Evaluation & Management (E&M) Coding 101
with Dr. Ryan Trojan
Dr. Ryan Trojan gives us a 101 on Evaluation and Management (E/M) Coding, including tips and tricks for capturing inpatient notes and practice building, as well as the updates for success in 2021. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Benefits of Evaluation and Management (E&M) Coding
(2) Templates for E&M Coding
(3) How Medical Decision-Making Affects E&M Coding
(4) Comprehensive Documentation in E&M Coding
(5) Common E&M Codes
(6) Specific E&M Codes (ER, ICU, Stroke)
(7) Recent Changes in E&M Coding
(8) E&M Coding Educational Resources
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[Chris Beck]
Ladies and gentlemen, welcome to the BackTable Podcast. If you're a new listener, welcome. For all of our regular listeners, welcome back and thank you for listening. BackTable is a podcast committed to all things IR and endovascular.
[Chris Beck]
I'm Chris Beck. I'll be your host today. I'm a private practice interventional radiologist based out of New Orleans, Louisiana. Today, we have another private practice interventional radiologist who's joining us, Dr. Ryan Trojan. Ryan, welcome to the podcast.
[Ryan Trojan]
Thank you for having me.
[Chris Beck]
Yeah, man. So, originally, you came under a radar when we saw your YouTube video about E&M coding. So, the topic today is E&M coding. Ryan, before we launched into the topic, will you tell everyone what your practice looks like and why even you made the E&M video to begin with?
[Ryan Trojan]
So, I practice at a hospital called INTEGRIS Baptist in Oklahoma City. I was in a private practice group, and we separated from the private practice group--the IR section did--and one of the things when we separated was we wanted to focus on E&M, whether that be inpatient or outpatient as added sources of work RV revenue and just to provide better clinical care.
So, in my current practice, I've been employed by the hospital as a 100% IR group for about two years now. We have five IRs, new neuro IRs and five IRPAs in the current practice.
[Chris Beck]
That's a pretty big practice.
[Ryan Trojan]
Yeah, it is.
[Chris Beck]
Yeah. What's the hospital system like? How big?
[Ryan Trojan]
So, it's a pretty big hospital system. It's interesting. It's a nonprofit private hospital, but we're the transplant center for the state of Oklahoma. So, we do all ECMO, and with that comes a host of bleeds and all the oncological work. So, the main hospital, it's licensed for 600+ beds, but they usually operate around 500 to 515, and then we have five other hospitals that feed in that don't have reliable IR practices. So, that's probably an additional 500 beds. So we do a lot of transplant work. We're a comprehensive stroke center in the IR department. We do the majority of the stroke interventions. So, it keeps us pretty busy.
[Chris Beck]
How many years out from fellowship are you?
[Ryan Trojan]
I am three years out.
[Chris Beck]
Three years out? Okay. All right. So, you're private practice IR, employee base, work for the hospital.
[Ryan Trojan]
Correct.
[Chris Beck]
When you made the jump from your old practice to this practice, did you look back? What's it like? Good, bad, ugly?
[Ryan Trojan]
Oh, it's great. So, I'll tell you. My first year out, being in a diagnostic group, I think it's somewhat like a dysfunctional marriage in that we were just together because we got kids, couldn't really separate, but yeah, it was a lot of infighting. As a marriage, we were headed in different directions. So, I would say it's one of the best decisions that I think we've made as a practice, and for my own personal life, I can tell you I am significantly happier working for the hospital because all I do is IR. I don't have to worry about looking at a stack, reading a diagnostic study.
So, for anybody that's thinking about it, I would say just cut the cord and do it, but it can be sticky. In the state of Oklahoma, the noncompete laws are nonexistent. So, it's a lot easier to separate from a group. I know other places it's a little bit more difficult.
(1) Benefits of Evaluation and Management (E&M) Coding
[Chris Beck]
Got you. Sure. All right. So, getting into E&M coding, what does E&M stand for?
[Ryan Trojan]
Evaluation and management.
[Chris Beck]
I mean, it's a softball question, but why should anyone care? I mean, couldn't you just go through just do a ton of 100% IR and then just skip all the E&M coding? What are the actual pros for some of the naysayers out there?
[Ryan Trojan]
So, I think the first pro is IR is moving more clinical, and so as we move more clinical, this is a huge piece. I think for practices that perform E&M, it's just better clinical care for the patients and it's a better patient experience. So, if you come see, I'm going to see you in consult, depending on the procedure, and then I'm going to see you for the procedure, and then any day you're in the hospital, I'm going to come in and see you and drop a note.
So, number one, I think it's better patient care. Number two, it's documentation. I think, especially if you're on-call on the weekends and there's a really sick patient and you decide not to intervene, then those are patients I would go see and put a consult note in so it's in the record as to why I didn't intervene. So many times interventional radiologists don't go see the patients and then stuff gets put in the chart that may not be accurate.
The third thing obvious would be increased work RV revenue. So, when you look at a vascular surgeon, for example, they get about 20% of their work RV revenue from E&M coding. I feel like as interventional radiologists we can do the same. You can have a 10% to 20% boost in your work RV revenue if you perform E&M coding.
[Chris Beck]
So, for those of you listening, also know that we will link to Ryan's YouTube lecture. That's the first thing how he came under our radar. So, if you guys are interested, please listen to it. It will be in the show notes. I noticed in the lecture you said that vascular surgery, it's 20% E&M. Now, you haven't hit the 20% mark. Is that the goal? Is that a reasonable goal for interventional radiologists? Where do you think people should stand in terms of how much are their billing coding should be E&M versus S&I or procedure codes?
[Ryan Trojan]
I think 10% to 20% is a reasonable goal. So, I hit my first year out 13%, but 90+% of that was inpatient. Still working on getting a big outpatient clinic setup. COVID derailed our plans for clinic space since we work for the hospital. If the hospital says no as far as funding, we have to wait, but I do think 10% is reasonable for most private practice radiologists if you just do inpatient E&M work, not even doing outpatient clinic.
[Chris Beck]
Okay. All right. That's fair. That's fair. One of the things that I think to bring some awareness and really hit home for people on the fence whether E&M is worth it or not, can you talk about some relative work RVUs in terms from some E&M codes versus some procedure codes and compare the two? A tip says 10 work RVUs, which I'm making up that number, and a level four visit is worth how many? Do you have any comparisons off the top?
[Ryan Trojan]
Yeah. So, a simple one, and we'll talk about this as far as inpatient work goes, you have what I call an inpatient hospital day one, which is 99222. It's a level two. Then, you've got subsequent hospital days, which is 99232.
[Chris Beck]
So, those are just progress notes.
[Ryan Trojan]
Yeah, the followup ones, they're progress notes. The hospital day one is 2.61 work RVUs. That's the exact same as a biliary drain change. Compared to other procedures like an F-tube is 6, a biliary drain placement is 7.6. So, for people who say, "I don't think E&M is worth it," if you look at some of the data--let's say an average IR-only physician does 8,500 work RVUs a year--they take 12 weeks of vacation, that ends up being 42.5 work RVUs per day if you work five-day weeks.
[Chris Beck]
Sure.
[Ryan Trojan]
So, if you can do 10 to 15 work RVUs just E&M, then the rest of it is just procedural stuff. So, I think everybody says, "Work RVUs aren't worth it," but it's one of those things that if you just do it everyday, then it's worth it. I have always rounded on my patients since I've been in practice, which isn't that long, three years, but I can't imagine not rounding on my inpatients. I can't see a day where I would do that.
[Chris Beck]
Right. That's just not your practice. I guess one of the things that I try to stress to interventional radiologists is that a lot of times in people's practice, you're already doing the work. Most of us will see patients, inpatient consults, go up to the floor and see patients, and a lot of us round on our patients after procedures. The only difference maker here is sometimes just the documentation and then capturing that billing code. So, has that resonated with some of your other IR partners in terms of they're doing the work, you just have to emphasize to them, "Man, all you gotta do is just drop the note, drop the code."
[Ryan Trojan]
That's correct. In order to do that, our staff demystifies a lot of misinformation that's out there and 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. In every other procedure, you can build postoperative day one for a progress note. So, one-
[Chris Beck]
Let me stop you only because I think that some people might gloss over this. What we're talking about is global billing periods. 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? You really don't need to sweat it that much except for a couple of circumstances.
[Ryan Trojan]
Yeah. So, global billion 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.
So, 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 are 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.
Back to your original question as far as implementation, for my older partners, I think that templates are very, very helpful.
[Chris Beck]
Sure. Okay. So, I think we've tackled the global billing period, and like you said, demystified it in a way. If I hear you correctly, one, 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, so like if you did gastrostomy, kyphoplasty, cholecystostomy tubes, and then any kind of ablation--then that falls under a 10-day global billing. For the next 10 days you can't bill, but everything else. So even though it's weird that a cholecystostomy is on there, but a biliary drain is okay, right?
[Ryan Trojan]
Correct, because they dropped the payment for biliary drains, not cholecystostomy.
[Chris Beck]
Right. So, that's the historical perspective: they dropped our S&I code and then they freed us up on the backend. So, now, as a profession, that's what we have to take advantage of, right?
[Ryan Trojan]
Correct.
(2) Templates for E&M Coding
[Chris Beck]
Okay. Will you talk a little bit about your templates? I guess, tell the audience what electronic medical record that you're using, and then how you use templates to your advantage and to make this process easier and less painful.
[Ryan Trojan]
So, I use EPIC and it's pretty simple. We'll try to provide copies of the templates, but the easiest thing I've found is that there's a way to go to the auto text editor to look at other people's templates. I stole all my templates from urologists, and just changed a few things to it, and then it was good to go. It auto imports everything. It brings in vitals, labs, I's and O's. I have a separate section that covers drain output, and any imaging report.
So, everyday, I have very minimal input into the note, and in EPIC, once you make a good note, it takes literally 30 seconds just to copy and paste it forward, change one or two sentences, and you're good to go.
[Chris Beck]
Absolutely. One thing that maybe the audience missed is that we're going to try and get Ryan's templates, if you would. You'll share some of those templates with us. So, for EPIC users out there, we'll have access to Ryan's templates. So, maybe you can borrow, modify, make them a little bit better or whatever, but we'll try and include those in the show notes, and if not in the show notes, we'll link to them wherever we can get them on the website.
After you put in your note, and this may be specific to different electronic medical records, then what? Do you just have someone who combs through all your notes or do you actually drop the charge that prompts a biller? How does the next step work?
[Ryan Trojan]
So, for both S&I coding and for E&M coding, we do our own billing. So, in EPIC, when it pops up, I have a box of different codes to choose from, and so then I just pick the code. Then that drops to a queue for our biller to approve it.
[Chris Beck]
Okay. Is it for some of your other partners who aren't as familiar with the codes? Is everyone so familiar that they know which ones to code for? Is there ever a time where, does anyone give you some assistance in this?
[Ryan Trojan]
Initially, when we transferred it over to the hospital, we had access to our hospital-based E&M billers, but now after two months, nobody has really any questions as to what the bill is because it's pretty straightforward on the three or four codes that we use.
[Chris Beck]
Okay. Nice. One of the other things I wanted to demystify before we started talking about the components of billing was a modifier 25 or dash 25. Will you, one, 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 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 was to evaluate whether they tolerate moderate sedation, do we need anesthesia, and 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, and 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 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.
[Ryan Trojan]
The modifier 25 stuff, the way I document it, the billers say it all goes through. So, I think, again, another piece of this information when it comes to E&M work.
[Chris Beck]
Yeah. No. That's important. Can you give us some procedures, maybe some good example of procedures where you do go see the patient ahead of time, like on a same-day procedure like you said a septic nephrostomy tube, if I had to extrapolate, probably a cholecystostomy tube, but maybe 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 call 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.
(3) How Medical Decision-Making Affects E&M Coding
[Chris Beck]
Okay. Got you. So from the billing component and from watching your video, I know that the medical decision making is the most important part. So, will you talk about the different components that go into medical decision making and then how that plays into driving everything else about the E&M code?
[Ryan Trojan]
So, the three components of calculating complexity of medical decision making are problem points, data points, and risk. There are four levels: straightforward, low complexity, moderate complexity, and high complexity. So, from an IR perspective, when we're figuring out and calculating complexity medical decision making, it's either going to be high complexity or moderate complexity. It's unusual to get a straightforward complexity or low complexity.
You have to remember, these charts and tools were designed for family medicine clinics. As an interventional radiologist, we just deal with a much sicker patient population. So, most of the stuff that I do is moderate complexity.
[Chris Beck]
Okay. So, basically, once you get through all components of the medical decision making, the four levels that you can end up at are: straightforward, low, moderate, and high. Basically, to make everything simple for everyone, you can throw away straightforward and low. That's just not the arena in which we work. Everything is going to be moderate or high. So, we're just trying to figure out where we end up in moderate and high.
All right. So, now, I think you said the three components that lead us to whether or not we're going to be at moderate or high or, and correct me if I'm wrong, the number of treatment options, that's number one, the amount of the data, that's two, and the risk category, right?
[Ryan Trojan]
So, the first one will be problem points instead of treatment options, and management options is one of the categories in risk.
[Chris Beck]
Got you.
[Ryan Trojan]
You only need two of the three. So, you would only need, for example on moderate, if you had problem points and data points, but the risk wasn't there, you would still qualify for moderate complexity because it's two out of three. When we look at the moderate complexity for medical decision making, so for problem points, it's very simple for interventional radiology to hit three problem points.
So, any past medical history counts. So, if you have a patient with acute polynephritis, and they have diabetes, hypertension, those are two problem points: hypertension, diabetes, and then, obviously, you've got an established problem which is worsening, which is acute polynephritis. That's at least two, if not three because it's a new problem. So, it's very easy to get to the three problem points because all of our patients have multiple, multiple past medical history problems. To plug in to the templated notes, on EPIC, all this stuff feeds in on your template for past medical. So, they're easy points to get.
[Chris Beck]
Yeah. I will say that as an EPIC user, the idea to hit the number three is so easy because, I mean, people's lists now are 12. I mean, if you've been in the hospital for any amount of time, there's 15 things there. So, it's like you hit right off the bat. So, that's the number of diagnoses, and then the next category is, what? Data review?
[Ryan Trojan]
It's data.
[Ryan Trojan]
Data review, it got overhauled in the 2021 changes, which we'll go over in the future, but it's, again, you only need three points. So, if you review labs, that's a point. If you review or order a radiology exam, that's a point. If you talk to another physician, that's a point. One thing that is clutch for interventional radiology is if you do independent review of imaging, that's two points. So, if I have a patient that I do a TIPS on, for example, I see them the next day and they got a chest X-ray, I'll just say, "I independently reviewed the chest X-ray. There's no findings of pulmonary hypertension, small right pleural effusion." That's an automatic two points on the data. Since my EPIC note auto-populated labs, I get points for the labs. So, I've already medically hit my moderate complexity.
[Chris Beck]
Yeah. I think as interventional radiologists, it's pretty imaging-rich. So, like you said, two points for the imaging review, one point for the data review, and then you've already got three points, so now you're at that moderate category in terms of the amount or complexity of data review. So, just to back up, so we've done the number of diagnoses, and then we just did the amount or complexity of the data reviewed, and then the next category is what?
[Ryan Trojan]
Risk.
[Chris Beck]
Okay. Let's talk about risk.
[Ryan Trojan]
Risk is complicated in the fact that within the risk category are three different categories. So, within the risk category, you have: presenting problem, diagnostic procedures ordered, and management options. So, from an IR perspective, I look at it as either presenting problems or management options, and in the risk section, you just need one of these categories to hit. So, I don't need two out of the three, I just need one out of the three.
So, for moderate complexity, if you have more than two stable chronic illnesses, that's moderate complexity. If you have an acute complicated injury, which is most of our patients, that's moderate complexity. Also, if they're a minor surgery with risk factors, then that's moderate complexity. So, anything with the 10-day global is a minor surgery. Anything with a 90-day global is considered a major surgery. So, just a little nomenclature there.
[Chris Beck]
Oh, that's a good question. So, if you have something like, say, nephrostomy tube that's not in that 10-day global period, is that not considered a minor surgery? That doesn't fit that bill?
[Ryan Trojan]
So, it would be considered a minor surgery. Minor surgeries are, correct myself, it's zero and 10-day globals.
[Chris Beck]
Oh, okay. All right. All right. So, almost everyone, so if we're looking at the risk category, within that there's three subsets, like you said, the presenting problems, the diagnostic procedures ordered, and management options, right?
[Ryan Trojan]
You're right. And the management option, that comes into play for the consult or the same-day note. Then everything after that is just going to kick back to problems because those will ride that patient throughout the hospital stay.
[Chris Beck]
Got you. This is just something I see a lot of people doing with their EPIC notes in terms of documentation. Do you say at some point you have to document that you have either chronic problems or stable problems or acute illnesses, whatever? I see a lot of people saying, "Patient is high risk, high complexity," or moderate risk, moderate complexity for these reasons. Is that a little blurb that you have in your note to state high complexity or not?
[Ryan Trojan]
I typically won't state that. If I'm seeing a patient in ICU and I'm going to bill critical care time, I'll talk about why they're critically ill. But if it's a floor patient, I'll just list all the problems on my assessment and plan.. So, let's say for the nephrostomy tube, it may be acute pyelonephritis or obstructive neuropathy, nephrostomy tube in place--they don't have a category for sepsis. I'll have another line for nephrostomy tube management, and then for antibiotic management I'll just say for primary. So, those are five different problem points that say the same thing.
[Chris Beck]
Got you. Okay. Then so once you've gotten done with risk, the amount of data reviewed, and the number of diagnoses, that takes you down to your final result for the complexity of medical decision making, and that can fall into four categories like we said. Will you say those four categories for us?
[Ryan Trojan]
Straightforward, low complexity, moderate complexity, and high complexity. Really, it's the difference between moderate complexity and high complexity, in my opinion.
[Chris Beck]
Okay. Yes. I think that's where most of us live. So, why is the medical decision making component so important because there's other components of billing, but why is this the component? Why would you make your case that this is the most important component because this is what drives the other two?
[Ryan Trojan]
Because this is the only thing that you can't change. So, if it's a moderate complexity clinical encounter, then you can select your code. Based on whatever code you select, like a hospital day one code, then you would just document your HPI and physical to mirror the requirements for that code.
[Chris Beck]
Okay. That's one of the concepts that I wanted to come through for the audience in that once you have your medical decision making, whether you're doing moderate or high in terms of the medical decision making, then you just build your note to meet those criteria, right?
[Ryan Trojan]
Correct. I'm pretty good with the computer. I think most people in our generation are. So, I typically just do a comprehensive HPI and exam on everybody, and then that way, it kicks it back to the billers to figure out if it's a moderate complexity case or a high complexity case. I was surprised at how many of my encounters got kicked up to a higher level code from the billers on the backend. I would say about 30% to 35% of my stuff gets up-billed based on my documentation.
[Chris Beck]
Okay. So, you just make sure everything is documented, and then the billers and coders will upgrade it on the backend. That's pretty neat.
(4) Comprehensive Documentation in E&M Coding
[Ryan Trojan]
Yes.
[Chris Beck]
Okay. Not that I want you to spend too much time because I think people will be able to borrow your notes, but what do you do in terms of documenting for history and physical exam that are just easy things to do, but also make sure that you have a very complete, well-rounded and, as you said, comprehensive note?
[Ryan Trojan]
So, everything is templated. In an EPIC, everybody knows that a lot of that stuff will auto-populate. Then to keep things simple on the HPI, for example, if I have to have a comprehensive HPI, that means I need greater than four description terms. So, those are location quality, severity, duration and timing, context, modifying factors and associated signs and symptoms. So, I just use very normal language and use their terms.
So, if I have a patient who has cholecystitis, for example, I'll say, "Location of pain right upper quadrant. Severity is nine out of 10. Duration is three days. Timing started two days ago." So, that way, the billers who most just graduated high school, not to dog them, but can go back in your note and find what they need to know. So, that's the most simple way I've found to do these.
[Chris Beck]
Okay. So, you basically try and give a roadmap and some very straightforward language, language that they're familiar with to help them mind your HPI notes.
[Ryan Trojan]
Yes. So, if you will get history, the three components of history are HPI, which is the highest level, it's comprehensive, and you only need four elements of the HPI, which is very easy to do. A complete review of systems is 10 things, and then past medical family and social history, you have to hit two to nine components in each of those areas. But almost all EPIC templates will auto-populate all of this stuff. If they've ever been to the ER or seen anybody, by the time an IR sees them, somebody else has put the stuff in the system.
[Chris Beck]
I would concur with that. Let me ask you this about the review of systems, and this is a little bit in the weeds. Do you do a review of systems for your patients? What does the review of systems looks like?
[Ryan Trojan]
It depends on the patient. If I'm seeing an outpatient consult for a cryoablation, I'll do a very extensive review of systems. If I'm seeing somebody in the hospital, it's a very truncated review of systems. I may even say on my review of systems, "Review of systems limited due to patient's status and current medical condition," or I'll just say, "Review of systems otherwise were not pertinent to this problem."
[Chris Beck]
Okay. For some people who are maybe asking this question, what about history components, where you're actually doing a lot of decision making and you're reviewing a lot of things, but your patient is not contributing to any of the history--like they're intubated? How do you pull anything? Go ahead.
[Ryan Trojan]
So, I'll provide a phrase that we've approved. Basically, we use it for stroke patients and intubated patients that says, "HPI not obtainable from patient due to X, Y, and Z," but I can provide that. It's one of my templated statements that I use in most situations.
[Chris Beck]
Okay. So, it's still okay to have a lot of the stuff in there even though you may gather it from other points of the chart, family members or something like that, right?
[Ryan Trojan]
Correct.
[Chris Beck]
Then the physical exam, I assume that you're doing pretty extensive physical exams and probably in the parlance of the E&M coding comprehensive physical exams. So, what does that look like on EPIC?
[Ryan Trojan]
So, it auto-populates, A, organ systems, which is a comprehensive exam.
Then I just go through those, and a couple free points that you get. If you have three vital signs in your note, that's considered a constitutional organ system. So, then you only have seven things to grab. So, I'll grab eyes, skin, lungs, abdomen, chest, extremities, and then typically I'll find something else to go over. Things I leave out: I don't do MSK, I don't do GU, I don't do hem-lymph, butI'll do a neuro exam. I keep it pretty simple, "Neuro, grossly normal. Respiratory, no respiratory distress."
[Ryan Trojan]
So, there are shortcuts.
[Chris Beck]
Yeah. I think some people unfamiliar with this arena are thinking that, "Maybe I have to start carrying around a stethoscope." That's a little bit daunting for them to be trying to pick up heart murmurs, but there's a lot you get when you walk into the room and assess the patient that you can document, especially I think EPIC makes this especially easy and you laid it out, like one of your assessments might be the eye exam and maybe it's extraocular, I mean, I don't know what you'd say, but-
[Ryan Trojan]
Normal.
[Chris Beck]
Yeah.
[Ryan Trojan]
Mouth, moist.
[Chris Beck]
Right, right. Okay. Neck, supple.
[Ryan Trojan]
Yeah. Neck, I'd just say no JVD.
[Chris Beck]
Okay.
[Ryan Trojan]
So, this is a very important part. I did drive this home with some of my senior partners. If you look at an inpatient progress note, which is a very normal code for us to do, all you have to do is to do an expanded problem-focused history. That's two body areas. So, if you have three vital signs in your note, that's one. Then typically what I'd do on that, I'll have skin, drain site is clean, dry, and intact, and that's it. Boom. Physical exam done.
So, it's very quick. When I do my rounds, I will talk with the patients and go over expected outcomes and a bunch of different things, but I'm not doing five-minute physical exam, just literally 10-second exams.
(5) Common E&M Codes
[Chris Beck]
Yeah. The exams happen basically when you walk in the room, and then you spend all the meaningful time with the patient doing a lot of counseling, which maybe isn't reimbursed well. So, I mean, I think that most people who do this get it. It's playing the game in a way to make it optimized for your scenario, but I think that's a lot of what an IR does is we have meaningful encounters in patients. We don't want to spend our time doing some random MSK or neuro exam when it's just not pertinent to us.
Now, I want to talk about some of the inpatient codes that, and we're getting a little bit into a numbers game, and so if people aren't following us, we can just reference the YouTube video, but what are the most common codes that you use because you mentioned that you're doing a lot of inpatient billing? What are the most common codes that fall into your billing and coding situation?
[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]
Sure, sure. So, going back to the admission H&P code, which you said was a very common code for you to drop, which for those listening, it was 99222. Is that a code that has to only happen on day one of their admission or is it 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 the midpoint of their hospital stay?
[Ryan Trojan]
Yes, 100%. So, that's the first time that I see them in the hospital.
[Ryan Trojan]
10 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 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? Or, do they fall back into another admission H&P? I mean, I know the answer to this, but I just wanted to hear what your opinion or how you would treat that.
[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 warrant 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. Again, I think that's a big place of confusion for most IRs. 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.
[Ryan Trojan]
So, a patient can be on hospital day 32, but it's hospital day one, and then everything else is 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.
[Ryan Trojan]
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. So, typically on those, 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 will document in my note, "We consulted, here are all the treatment options. Patient elects 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 or 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: 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.
[Chris Beck]
I see. So, that's your gut check whether or not the procedure is actually in the air or not.
[Ryan Trojan]
So, kyphoplasty, for example. 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.
[Chris Beck]
Okay. Got you. I think that's probably sophomore level billing and coding, but it felt like we should throw it out there.
[Ryan Trojan]
It's getting up there.
(6) Specific E&M Codes (ER, ICU, Stroke)
[Chris Beck]
Yeah, it is. Right, right. So, Ryan, 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. Not that we have to get into the actual numbers on that, but will you just talk a little bit like maybe someone who's starting to want to push their practice in 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. If I see a patient in the ER, 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 the patient goes home. The 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 patient, again, I keep circling back to these cholecystostomy tubes or neph tubes, but it seems like those are always the sick patients.
[Ryan Trojan]
Another good example is a stroke patient. 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. Wanted 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.
(7) Recent Changes in E&M Coding
[Chris Beck]
Okay. Great. All right. So, one of the things I wanted to switch gears and talk about how these things always feel like a moving target. There were some changes for 2021. Can you just give us the 30,000-foot view of what changed for 2021 in terms of E&M billing and coding?
[Ryan Trojan]
Yes. So, the 2021 changes, it's about the most excitement that these things have had since 1997. Again, this stuff has been in effect since 1995, 1997. 1995, I was nine years old. Since then, we've had no changes, whatsoever. So, January 1st 2021, the new changes took place. I think these changes will eventually apply to inpatient work.
Right now, the new changes only apply to outpatient work. So, outpatient, where you see a new patient for the first time, and then outpatient, where you see a followup patient. Just to briefly go over what they did, so if you're going to see a new office patient, there used to be five codes, 9920--1 through 5--level one, two, three, four, five. If you look at CMS data, nobody bills a level one office note. So, they just deleted that code.
Then they made it to where the codes are either based on medical decision making or time as a driving factor. The medical decision making chart got tweaked a little bit, and then the time component was changed by a significant amount. Let me grab this chart real quick.
[Ryan Trojan]
So, the old coding was based on time, again, I don't think we should talk about this briefly, but I don't typically code based on time. I will code base on time if I end up in some 70-meeting with a family about de escalation of care or I'm just using the time to capture the work I did.
So, the old coding based on time, you had to spend the entire time face-to-face with the patient, over half the time had to be devoted to counseling and our coordination of care, and then you had to document the time spent and the nature of counseling and coordination of care. That's the old stuff. The new changes, I think they've done a pretty good job on revamping this to where it's friendly for the physician.
[Chris Beck]
Right. It's more reflective of people's practices now.
[Ryan Trojan]
So, the new coding based on time can include face-to-face time, can also include non-face-to-face time before and after of the visit on the date of the encounter, and there are no requirements regarding counseling and our coordination of care. So, basically, any time spent preparing to see the patient, seeing the patient or working on the note after can qualify. It really makes things a whole lot easier, and then I think with these new outpatient time-based billing criteria, it's going to make it to where time-based billing is a lot more feasible for IR physicians out there because component-based billing is complex like we've just been talking about. There is a lot of lingo and other things that could be confusing to somebody starting out.
[Chris Beck]
Well, I guess that was the whole reason I wanted to have you on is that I feel like on the surface, it feels like billing and coding is you're constantly going to get trapped, and if you don't have the right thing, it's very tough. One of the things I hope that comes across in this discussion is that a lot of the stuff is it's like you're already doing it. You just have to make an extra small effort to make sure that your documentation is tight because it's work that interventionalists are all doing. I think a lot of us are going to see our patients. We're having these conversations with patients and family. We're spending the time with them. We're doing our assessments.
Then I think a lot of our documentation, it's almost all there, and I think these electronic medical records are making it to where it's super easy to just capture a couple of extra data points to where we're hitting all the markers that we can to capture appropriate codes.
[Ryan Trojan]
One more thing I forgot to mention about the 2021 E&M guidelines: the history and exam are thrown out. So, you can do whatever history and exam you feel is medically appropriate for the patient. So, all this stuff we're talking about before, the physical exam and the history needs to hit all the points based on whatever notes you're coding for. With the new 2021 outpatient E&M guidelines, it's either based on medical decision making or time. So, it's going to simplify everything.
One thing I would recommend for at least the young IRs, when I started my practice or joined the practice I'm in now, typically, it wasn't standard for us. We would go see some of our patients, but not all of our patients. So, my first year rounding on patients, a lot of the physicians were like, "You're IR. What are you doing on rounds?" when I would round in the different ICUs, and then after about six months, it got to be where that was expected, and then 12 months, a lot of the guys that I would see up in the ICU would then call me with problems directly just because we were constantly seeing each other rounding. So, for me, starting out in the IR practice, it made it to where I was approachable to other providers, and it made us more open for referrals, I think, moving forward and growing the practice.
[Chris Beck]
No, I think it's a positive feedback loop. I mean, one of the things that we haven't talked about is just doing this work of going up and seeing patients just increases your visibility a thousandfold. Gone are the days or people who just sit back and you're just waiting for a consult to come through or waiting for someone to call you with a case. I think it's invaluable building that bridges relationships with the referring docs. So, no, no, I totally agree.
[Ryan Trojan]
We have five PAs in our practice or four PAs. We're adding a fifth. We do not have them do E&M work. They just do peritoneal dialysis catheters and a few other things. I think it's better for the IR providers to perform the E&M themselves than to have a mid-level just because it improves your, like we were talking about, improves your visibility, and then it gets you face-to-face time with the patient.
This is one of the sticking points why we left our diagnostic group: we weren't getting clinical time. We wanted to start a clinic. We wanted time for rounds. The diagnostic group just wasn't in line with what our objectives were. We all sat down and said, "We've got to figure out how we want to design this practice," and a lot of us get energy from seeing patients, seeing providers on rounds. There's a lot of positive feedback.
Then you go hang out with your diagnostic colleagues, and it's just a lot of negativity. It reminded me of a dysfunctional high school relationship where you got that crazy girlfriend that's stealing your shirt, and then yelling at you all the time. So, I can tell you after doing 100% IR practice, doing E&M aggressively for two years, I can't imagine practicing any other way. I think the SIR talks really big about the need to do clinical medicine, but we don't have the resources for a lot of interventional radiologists to jump in because we are not taught this. Every other specialty like urology, what my twin brother does, I mean, they go over this stuff all the time.
(8) E&M Coding Educational Resources
[Chris Beck]
So, yeah. So, talk about how you got into this and what were some of the resources that you used because I know one of the things that SIR has is there's the SIR toolkit, which I'll link to. I've looked over that a couple of times, but what did you use? Did you borrow an experience from other people or did you have any resources that we can link to?
[Ryan Trojan]
So, the toolkit is basically just the carbon copy, the stuff that the government puts out. So, that's the first thing I did. I looked at the toolkit and I was like, "Well, this isn't very good." Then I called my brother and he's like, "You're going to have to go to a course." Then I was like, "First year of practice, I don't have any vacation."
So, emuniversity.com is by far the best resource. It's an online resource. You have to pay for membership, but that's what I recommend for any of this stuff. You may be the guy in your group that's going to focus on this aspect of the practice, and that would be the best place to get expert level education. It counts for CME, and it's only a couple of hundred bucks.
[Chris Beck]
Okay. Also, understand that you have a handbook that you've made for your group.
[Ryan Trojan]
Yes. I have a handbook that we'll provide copies of. I don't know how we get it out there, but-
[Chris Beck]
We'll get it out there, man. We'll get it out there. Don't worry.
[Ryan Trojan]
All of my stuff is free. You can do whatever you want with it. I don't wear a white coat. I just wear a vest, but it fits in the pocket of your vest, and it's a good resource to reference.
[Chris Beck]
All right. We'll do that. Then also, we'll also link to your YouTube video, which, personally, I got a lot of value from. Clearly, you put a lot of work into it. So, I hope people go and check it out. Was it tough to make?
[Ryan Trojan]
Yeah. I mean, as you can tell, probably not the best podcast speaker, but it just took a lot of time. So, E&M work a lot of times is just like--you got to do it a couple of times and then you figure stuff out. So, you just got to pull the trigger and start doing it. Then once you start doing it, then you'll know what questions to ask. So, my partners will tell you when we first started doing this, I had multiple PowerPoints, and they were horrible because I just had no idea what I was doing. Then after 12 months, I could really boil it down to these are the pertinent points.
So, I'm also going to try to get a 2021 update video out because, again, I think that in a year or two, this 2021 update is going to apply to all inpatient work. It's going to really make it to where any IR will be able to bill for this kind of stuff and document appropriately.
[Chris Beck]
So, the last question, although we could have easily ended on that note, is if someone is asking for your opinion on a case, say a surgeon comes down and wants to know if you can drain an abscess, and you haven't seen the patients, it's like a sidewalk consult situation, where you're able to look at the pictures with the surgeon there, and you know you don't have a window. How do you handle that situation? Do you just ask them to put in the consult and you're like, "Look, put in the consult and I'll work everything on the backend," or is there something you do with those that either you know can go or can't go to your IR procedure? Do you know what I mean?
[Ryan Trojan]
Yeah. So, it depends on my, to be honest with you, my day. If I'm getting slammed and I'm booked out till 9:00 PM, then I may not go see that patient. If I trust the surgeon, which all the surgeons at my hospital I trust, but most of the time, especially if it's the weekend, I feel like my consults really get ramped up on the weekends, I'll go see the patient.
Then one simple thing I've done that added to the practice and people love it, the snipping tool. Do you use that on your notes?
[Chris Beck]
No. I'm not familiar with it. So, go ahead.
[Ryan Trojan]
I blow it up.
[Chris Beck]
Nice.
[Ryan Trojan]
I snip. If I see there's no window, I'll snip the abscess and I will annotate colon abscess and I'll say, "See? I can't stick a drain in that." We do all these crazy cases like we'll do crazy TIPS, but nobody cares. I had a patient that had horrible head and neck cancer, and I recanalized their upper venous system, and put kissing stents down to the SVC. It's really not that complex of a procedure, but I put notes on it, and people flipped out. All the ICU intensivists were like, "Oh, that's amazing." The nurses were pumped. So, I realized then you just put pictures up there and people just love it.
[Chris Beck]
That's such a pro move there, and I think I will borrow that. So, all it is is just using the snipping tool and then that's how you import the picture in?
[Ryan Trojan]
Yeah.
[Chris Beck]
That's great.
[Ryan Trojan]
Like on the finding step, I just put pictures.
[Chris Beck]
That's awesome. That's awesome. Okay. All right. Well, I think that wraps it up. Any final thoughts about E&M or any final thoughts about billing and coding in general, Ryan?
[Ryan Trojan]
I think it's going to be a moving target. I think if you're not doing E&M, I think that you're not practicing to the full potential of an interventional radiologist. We know it's the right thing to do to go see our patients. We know it's the right thing to see them in consult, to see them in clinic. So, I would just say jump in and do it. For all you guys in the diagnostic group, where you're trying to justify an outpatient clinic, my advice is: for six months, do inpatient E&M coding. There's no overhead associated with it. You get a new revenue source. Then go to your group and say, "Hey, look how successful we've been on the inpatient side. Now, give us some money for an outpatient clinic that we know is going to lose money," and then you may be more successful. I'm also one that would say just do 100% IR, but I think I'm in the minority on that one.
[Chris Beck]
For everyone, it's an individual thing. Certainly, I think that there are people who are in relationships where they work well with their diagnostic colleagues. Not everything is butting heads, although that's certainly what we hear about more.
[Ryan Trojan]
I would say that I agree with you that I think that moving forward is going to be a combination of everybody's picture, right? People who maybe do 50% IR, some that do 90%, and usually the market dictates that. So, I'm not trying to hate the diagnostic guys.
[Chris Beck]
No, no, no. No hate towards the diagnostic guys. All right. I think that that covers it. To the audience, thank you guys for listening. We covered a good topic today. If you heard us reference Ryan's video, we're going to link to that YouTube video in our show notes, and we're going to have links to a lot of other things. I don't have it all figured out right now, but we got some smart team members that are going to make sure it's going to be available to you. So, check out the show notes and check things out on backtable.com.
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[Ryan Trojan]
Thank you.
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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