Evaluation and Management (E/M) coding has undergone significant changes in recent years, creating new challenges for medical coders, a real risk to reimbursement, and the threat of compliance pitfalls. With updated guidelines introduced in 2021 and expanded in 2023, coders must navigate new documentation requirements, time-based coding options, and changes to medical decision-making (MDM) criteria. Although these updates aim to simplify processes, they still may spell trouble for coders and require a deep understanding of the rules to ensure compliance and accurate reimbursement. For interventional radiology and other specialties, determining when to report E/M services separately adds another layer of complexity in an area already proven to be an arena of challenge.
Evaluating E/M Basics
Navigating Evaluation and Management (E/M) codes can feel like a moving target, but staying up to date is crucial for accurate documentation and reimbursement. These codes cover a variety of entities including:
- office visits
- hospital stays
- emergency department visits
- nursing facility care
- and home visits
Essentially, they apply to any patient encounter that doesn’t involve a separately billable procedure.
It is critical to note that big changes in E/M coding have advanced in recent years causing added complexity. Back in 2021, new guidelines simplified documentation and coding for Office or Other Outpatient E/M services. Then, in 2023, updates expanded to all other E/M categories. These include:
- Hospital
- emergency department
- consultations
- nursing facility
- and home care visits.
These changes affect all physicians and qualified healthcare professionals (QHPs), requiring them to follow the updated guidelines for every E/M encounter.
To keep up, providers, coders, and billing professionals should familiarize themselves with the latest guidelines, originally published in the 2021 CPT® manual and updated in 2023 by the AMA and specialty societies. Physicians, QHPs, and coders should become familiar with the new guidelines as they have significantly changed the coding and documentation of E/M services.
Ultimately, E/M codes describe office, hospital, emergency department, nursing facility, and home visits with the patient when not performing a procedure that is represented by another specific CPT code.
Time or MDM? How to Select the Right E/M Code
When selecting the appropriate E/M service level, providers now have two main options: basing it on total time or medical decision-making (MDM)—with one key exception. Emergency department E/M services must be selected using MDM only, making them unique among the categories. One of the biggest shifts in E/M coding was the removal of history and physical examination as determining factors. Because of this change, many lower-level E/M codes were eliminated, as they were previously distinguished by those now-defunct elements.
If you’re choosing time as your method for code selection, it’s important to note that total time includes not only the face-to-face interaction with the patient but also non-face-to-face activities related to their care on the same date. Each E/M service code now has updated time specifications, so understanding these adjustments is crucial for accurate coding and reimbursement.
Mastering MDM Elements for Correct Coding
The CPT manual also includes a new MDM chart describing new MDM elements required for each of the E/M service codes. The good news is that the MDM elements are consistent across all E/M codes.
For interventional radiology (IR), the first question to ask is whether it is appropriate to report an E/M service. Situations that are not appropriate for billing a separate E/M service include:
- History and physical related to a procedure
- Informed consent for a procedure (i.e., explaining risks and complications and describing procedures to the patient)
- Post-operative visits related to the procedure
- The above three items are included in the payment for the procedure.
- Situations that may be appropriate for billing a separate E/M visit include:
- Visits when the patient sees the IR physician to determine if a procedure would be appropriate. However, according to NCCI, if the decision for surgery is made on the same day of the procedure, the E/M may be separately billed only if the procedure performed is a major procedure.
Modifier 57 would be necessary if the procedure has a 90-day global postoperative period and the E/M is performed the same day or the day preceding the procedure.
Modifier 25 would be necessary if the procedure has a 0-or 10-day global period, and the E/M can only be billed with modifier 25 if the service is significantly, separately identifiable (unrelated to the decision for surgery).
E/M most often, is included in the procedure code. Visits outside the global period may be separately billed if the visit fits all other guidelines. Visits during the global period that are unrelated to the procedure performed may be separately billed with modifier 24.
More information on E/M services may be found in the following resources:
• AMA CPT Professional Edition
• CMS Evaluation and Management Services Guide
These are not all the tips necessary. Equipping coders with the educational tools they need is essential for success for several key reasons that impact both your bottom line and compliance:
- Coding for Evolving Technologies
New IR techniques and devices are continually being developed. Education helps coders adapt to emerging procedures and technologies.
- Appropriate Modifier Use
IR coding often requires specific modifiers to indicate procedure nuances or to comply with payer requirements. Modifiers can make or break accurate coding, and each modifier has its own rules and nuances. Training helps coders apply modifiers accurately.
- Financial Impact
Accurate coding directly affects reimbursement and the financial health of healthcare organizations. Education helps coders optimize coding accuracy and prevent revenue loss. Inaccurate coding leads to less payment per code or even straight-out denials.
- Documentation Challenges
Accurate coding relies on comprehensive and precise physician documentation. Education teaches coders how to interpret and query unclear documentation. Documentation remains a universal challenge in every modality because of its level of variance and complexity and often the lack of time for communication between the treating physician and other professionals.
By equipping IR coders with comprehensive educational resources, organizations can ensure accuracy, compliance, and efficiency in their billing and reimbursement processes.Fortunately, we have a complete solution tailored to everyone’s specific learning needs. Our Interventional Radiology Coding: A Starter Kit. A combination of key resources delivers unprecedented expert guidance to master coding conundrums. Explore today.
