Can interventional radiologists (IRs) bill evaluation and management (E&M) codes? What do Medicare's global surgery rules have to say about when and how to assign them?
Our company's consultants are being asked questions about E&M codes more often than usual, so it's time to shed some light on a complex topic that many radiology coding professionals and radiologists find confusing.
One good source is the "National Correct Coding Initiative Policy Manual for Medicare Services," Chapter 9 -- Radiology Services, Section B, which covers Medicare's global surgery rules and reporting E&M services performed for procedures.
Global periods
All procedures on the Medicare Physician Fee Schedule (MPFS) are assigned one of the following global periods:
- 000 or 010: These indicate either minor surgical procedures or endoscopies.
- 090: This indicates major surgeries.
- XXX: The global concept does not apply to XXX procedures.
- YYY: Carriers (Medicare administrative contractors [MACs] processing practitioner service claims) determine whether the global period will be 0, 10, or 90 days.
- ZZZ: Surgical codes with this global period are related to another procedure (add-on codes), and the applicable global period is determined by the related procedure.
- MMM: This global period applies to maternity procedures.
Global surgery rules
National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits are applied to same-day services by the same provider to the same beneficiary, and the following are included in the global surgery rules that apply:
- An E&M service is separately reportable on the same date of service (DOS) as a procedure with a global period of 000, 010, or 090 under limited circumstances.
- If an E&M is performed on the same DOS as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57 (decision for surgery).
Other preoperative E&M services on the same DOS as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare carriers have separate edits.
In general, E&M services on the same DOS as the minor surgical procedure (global period of 000 and 010) are included in the procedure's payment. The decision to perform a minor surgical procedure is included in the procedure payment and should not be reported separately as an E&M service.
However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25 (significant, separately identifiable E&M service by the same physician or other qualified healthcare [QHC] professional on the same day of the procedure or other service). The E&M service and minor surgical procedure do not require different diagnoses.
If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same DOS as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.
For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package, as are E&M services related to complications. Postoperative visits unrelated to the diagnosis for which the procedure was performed (unless related to a complication) may be reported separately on the same day as a procedure with modifier 24 (unrelated E&M service by the same physician or other QHC professional during a postoperative period).
Procedures with a global surgery indicator of XXX are not covered by these rules because physicians usually perform the inherent preprocedure, intraprocedure, and postprocedure work each time the procedure is completed. This work should never be reported as a separate E&M code.
Other XXX procedures are not usually performed by a physician and have no physician work relative value units (RVUs) associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure.
With most XXX procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the XXX procedure but cannot include any work inherent in that procedure, supervision of others performing it, or time for interpreting the results. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same DOS as an XXX procedure is correct coding.
Tips on IR procedures
Most IR procedures are considered minor surgical procedures, and physician interaction generally involves limited pertinent historical inquiry about the following:
- Reasons for the examination
- The presence of allergies
- Acquisition of informed consent
- Discussion of follow-up
- Review of the medical record
In this setting, a separate E&M service is not reported.
As a rule, an E&M code is not reported separately if the medical decision-making that evolves from the procurement of the information from the patient is limited to whether or not the procedure should be performed or whether comorbidity may impact the procedure, or if it involves discussion and education with the patient.
If a significant, separately identifiable service is rendered that involves taking a history, performing an exam, and making medical decisions distinct from the procedure, the appropriate E&M service may be reported. This situation generally applies when the IR physician has a separate practice, and a patient is sent to determine the best course of treatment (but not for a specific procedure).
Donna Richmond is a senior healthcare consultant, clinical consulting services, for Panacea Healthcare Solutions. In addition to her coding hotline responsibilities for Panacea, she performs a variety of radiology and cardiology audits and contributes to several webcasts and publications, including MedLearn Publishing's new Basics of Interventional Radiology Coding book.
