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BackTable / VI / Article
E&M Coding for Interventional Radiologists: An Overview
Lauren Fang • May 30, 2021 • 795 hits
Evaluation and management (E&M) coding requires documentation to capture physician-patient encounters so that physicians are reimbursed appropriately based on the level of clinical care they deliver. Interventional radiologist Dr. Ryan Trojan provides an E&M coding overview, describing reasons why IRs should be taking advantage of it and how the medical decision making component of E&M works.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• Many IRs are performing E&M work on inpatient consults by visiting and examining patients on the floor, but they aren’t necessarily receiving the maximum compensation. There is an opportunity to change this with better E&M documentation to capture the appropriate billing code, which also helps boost Relative Value Unit (RVU). In addition to helping IRs practice at full potential, E&M also benefits the healthcare system by supporting better overall clinical care and accurate documentation.
• The medical decision making complexity component of E&M coding is one of the most important, as it drives the reimbursement level. Most IR physician-patient encounters will be of moderate or high complexity. Three possible criteria are assessed to differentiate between the complexity levels: number of problems, amount of data reviewed or ordered, and risk category. A criterion is fulfilled when a certain number of points is acquired, typically two out of three points.
Table of Contents
(1) Why Start E&M Coding?
(2) Medical Decision Making Drives E&M Reimbursement
Why Start E&M Coding?
The benefits of performing E&M coding include a better patient experience and overall clinical care, accurate documentation, and increased work RV revenue. Dr. Trojan states that it is possible for most IRs to see a 10% to 20% boost in work RV revenue if they are performing E&M coding. RVUs, when done everyday, can bring value. This is illustrated by the fact that some patient encounters, when compared to procedure work, can be valued similarly. For example, inpatient E&M coding for a hospital day one visit and biliary drain change are both appraised at 2.61 work RVUs.
[Chris Beck]
So, getting into E&M coding, what does E&M stand for?
[Ryan Trojan]
Evaluation and management.
[Chris Beck]
… Why should anyone care? Couldn't you 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. I'm going to see you in consult, depending on the procedure, and then I'm going to see you for the procedure. 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, 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]
[In your YouTube 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 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 plus percent 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]
I want 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 of E&M codes versus some procedure codes and compare the two? Do you have any comparisons off the top?
[Ryan Trojan]
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, and then you've got subsequent hospital days, which is 99232. 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 six, 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, and that ends up being 42.5 work RVUs per day if you work five-day weeks… 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 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.
[Chris Beck]
Right. That's just not your practice. I guess one of the things that I try and 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… You just have to emphasize to them, "Man, all you got to do is just drop the note, drop the code…” The historical perspective is 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… 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 we 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…. 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, 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.
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Medical Decision Making Drives E&M Reimbursement
The medical decision making complexity component of E&M coding drives the reimbursement amount for the physician. There are four levels of medical decision making complexity including straightforward, low complexity, moderate complexity, and high complexity. However, given the patient population that IRs work with, most encounters will be of moderate or high complexity. Three criteria are assessed to differentiate between the complexity levels: number of problems, amount of data reviewed or ordered, and risk category. As long as two of the three criteria are met, the complexity can be characterized as moderate.
[Chris Beck]
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 in the 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 of medical decision making, it's either going to be high complexity or moderate complexity. It's unusual to get a straightforward or low complexity medical decision making. 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]
… 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. All right. You said the three components that lead us to whether or not we're going to be at moderate or high are the number of [problem points], the amount of the data, and the risk category, right?
[Ryan Trojan]
[Yes]. You only need two of the three. 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. 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. Then, obviously, you've got an established problem that 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]
I will say that as an EPIC user, all that stuff auto populates. The idea to hit the number three is so easy because 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. All right. So, that's the number of diagnoses, and then the next category is, what? Data review?
[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, 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. 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, a nephrostomy tube, it would be considered a minor surgery. Minor surgeries are, I correct myself, zero and 10-day globals.
[Chris Beck]
So, if we're looking at the risk category, within that there's three subsets, the presenting problems, the diagnostic procedures ordered, and management options, right?
[Ryan Trojan]
You're right. In the management option, that comes into play for the consult or the same-day note. Everything after that is just going to kick back to problems because those will ride that patient throughout the hospital stay.
[Chris Beck]
Do you 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 out on my assessment and plan, I'll just put all the problems. So, let's say the nephrostomy tube, it may be acute polynephritis 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 antibiotic management I'll just say for primary. So, those are five different problem points that say the same thing.
[Chris Beck]
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… Why is the medical decision making component so important? There's other components of billing, but why is this the component?
[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]
Once you have your medical decision making, whether you're doing moderate or high in terms of the medical decision making, then from there, 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 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.
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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