Breast Center Bulletin
Published by the National Consortium of Breast Centers, Inc.
This newsletter is an opportunity for members to discuss programs and products but does not represent an endorsement by the NCBC.
No. 76, January 2006 2ISNN 0895-6677
NEWSLETTER EDITOR Claudia Z. Lee, MBA
Breast Center Consultations, Hudson, NY
PRESIDENT Jay R. Parikh, MD, FRCP(c)
Swedish Cancer Institute, Seattle, WA
Continuing education is a huge part of life for most health care professionals, and it is one of the most important missions of our organization.
Volunteers who work on the committees in the Education and Research Division take their jobs very seriously. As with all the other committees in the four divisions, all NCBC members benefit from their work. The Education and Research Division is composed of four committees.
Organizing the annual national conference is a major undertaking, and the members of the Conference Program Committee rise to the occasion. Chaired this year by Dr. Kevin Hughes, MD, FACS, Director of the Avon Foundation
Comprehensive Breast Evaluation Center at Massachusetts General Hospital, this committee’s goals are to: design the annual national
interdisciplinary conference; interface with the Corporate Liaison Committee for sponsorship and
recruitment; recruit speakers to fulfill the requests of the membership and/or Program Committee; recruit
interdisciplinary representation on the committee; decide upon and announce the recipient of
by Jay Parikh, MD, President of NCBC Continued on page 2
Is a High
Conference Exhibitors Show Latest Products, Information
Evaluation and management (E&M) codes are billed by most medical specialties, and visit coding has been a common thread across the different practices. Physicians who do not see and examine the patient and who are primarily involved in diagnostic services such as pathology or radiology are generally not expected to submit E&M codes. However, with the evolution of radiology practice into highly specialized departments such as breast centers, the radiologist is more often taking on the role of a treating physician and is seeing and examining the patient, as well as playing an important role in decision-making.
If all of the criteria for evaluation and management are met and properly documented, then no physician regardless of specialty (or other provider authorized to perform these services) is precluded from billing E&M codes. Some 225,000 E&M codes were billed to Medicare by radiologists (specialty code 30 reflects physicians specializing
Evaluation & Management Visit Coding By Radiologists
by Susan Granucci, CCS-P, Albequerque, NM
in radiology) in 2003 and in 2004, according to the most current Medicare database available. 1
Here is what Medicare has to say on this topic:
When physician interaction with a patient is necessary to accomplish a radiographic procedure, typically occurring in invasive or interventional radiology, the interaction generally involves limited pertinent historical inquiry about reasons for the examination, the presence of allergies, acquisition of informed consent, discussion of follow-up, and the review of the medical record. In this setting, a separate evaluation and management service is not reported. As a rule, 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, whether comorbidity may impact the
procedure, or involves discussion and education with the patient, an evaluation/ management code is not reported separately. If a
significant, separately identifiable service is rendered, involving taking a history, performing an exam, and making medical decisions distinct from the procedure, the appropriate evaluation and management service can be reported. The appropriate
evaluation and management service code is chosen based on the type of service rendered which satisfies the Evaluation and Management guidelines developed by the AMA and CMS. Medicare’s Correct Coding Initiative 10/1/052
Once it is determined that evaluation and management is medically necessary and appropriate, these are some of the guidelines for documentation3:
Separately Identifiable: The Continued on page 2
One of the highlights of the NCBC Annual National Interdisciplinary Breast Center Conference is the Exhibit Hall, where conference attendees can see the latest cutting-edge technology, talk to the company representatives and try equipment or patient-friendly devices.
To give all attendees a chance to visit the exhibitors, they are located just outside the breakout rooms, and all meals and snack breaks are scheduled in the Exhibit Hall.
Evaluation and Management Visit Coding by Radiologists Continued from page 1
E&M documentation must stand alone (separate from imaging or biopsy or other procedure) to qualify for payment. Documentation for a visit or consultation should not be merged with the imaging or procedure report. The medical record may consist of a legible handwritten SOAP note or dictation. It is recommended that any consultation codes (99241-99245 for outpatient/office) be more formally documented by a dictated note.
The key elements of E&M are a) history,
b) physical examination, and
c) medical decision making or assessment and plan.
The code level is determined by the level of detail or complexity documented in each of these key components.
For example, a level 2 established patient office visit (99212) is expected to average 10 minutes face-to-face time between the physician and patient, and have the following level of detail:
• A chief complaint/reason for visit with history of present illness consisting of one to three elements
• A physical exam – Onw body area or system (e.g., breast) • Medical decision-making – straightforward (e.g., ultrasound). A level 2 consultation (99242) is expected to average 30 minutes face-to-face time between the physician and patient in an office or outpatient setting, and have the following level of detail:
• A chief complaint/reason for visit with history of present illness consisting of one to three elements with at least one review of system • A physical exam – Two to four body areas or systems (e.g., breast, lymph nodes, lungs, heart, extremities for edema, skin, vitals and general appearance)
• Medical decision-making – straightforward (e.g., ultrasound For established patients, two of the three bulleted items or key components need to be documented. For new patients or consultations, all three key components need to be documented. When counseling or coordination of care dominate the visit, then an exception applies to these documentation elements, and coding is based on documented time. (See following topic on “Time.”)
Expected Code Levels
For established patients, defined as patients seen within the last 3 years, code 99211 implies a nurse only visit. Consequently, for physician visits, CPT 99212 or higher should be coded. For new patients or consultations, level 1 or 2 would be more common for radiologist billing in the absence of extended time or other extenuating circumstances, since standards for upper code levels are more difficult to meet.
Hospital, Providence, RI. Goals of this committee are to recruit abstracts/posters for presentation at the annual national conference; identify criteria for acceptance of abstracts/posters for display and/or presentation at the conference; arrange auditing and peer review for poster submission for the annual conference and interface with the Conference Program Committee.
The CBE Committee, which now is piloting its certification program in Tennessee and will go national at the NCBC annual Education is a High Priority for NCBC
Continued from page 1 the annual Impact Award; ensure that the Clinical Breast Examination (CBE) course is part of the annual national conference; interface with other nonprofit sister or corporate organizations for their participation at the conference; and oversee the development of the
An increasingly important group is the Abstract/Poster Committee, chaired by Don Dizon, MD, Director and Medical Oncologist in women’s oncology at Women’s and Infants
national conference in March 2006, is headed by Suzanne Taylor, MD, Primary Breast Care Consultant in Longview, TX. This committee is charged with designing and
implementing a national clinical breast examination certification program, biannually evaluating the content of the course, and establishing a peer review team for the CBE course evaluation.
The last committee in the Education and Research Division is the Web Seminar Series Committee, which is not yet operational but is being investigated on behalf of the
board of trustees.
All of NCBC’s committees are vital to our organization’s mission. These committees – and the volunteers who serve on them – help us all grow as medical professionals, which, in turn, helps us better serve our patients.
If you are interested in serving on a committee and would like to help us with our mission, please contact the NCBC office at 574-267-8058. For more information, please visit the NCBC website at www.breastcare.org.
History Components — In addition to the chief complaint or
reason for visit, the following are documentation guidelines provided by AMA:
Physical Examination Elements (1995 criteria) — A check list or
notation of any of the following items qualifies as an element in the documentation guidelines for the physical examination.
Body areas — head, face, neck, chest, breasts, abdomen, genitals, groin, back, spine, extremities.
Organ systems — constitutional (vitals, general appearance), eyes, — genital-urologic, ears-nose-throat, mouth, skin, respiratory, integumentary, cardiovascular, musculoskeletal, gastrointestinal, — neurological, lymphatic/hematologic/ immunological, psychiatric.
Code Level Hist. of Present Illness Review of Systems Past, Family, Social History Problem Focused 99212 99201 99241 Brief 1-3 HPI elements documented None None Expanded Problem Focused 99213 99202 99242 Brief 1-3 HPI elements documented Problem Specific (1 system) None Detailed 99214 99203 99243 Extended > 4 HPI or status of > 3 chronic conditions documented Extended (2-9 systems) Pertinent At least 1 item from
at least 1 history Comprehensive 99215 99204-99205 99244-99245 Extended > 4 HPI or status of > 3 chronic conditions documented Complete (10 or more systems, or some
with all others negative)
Complete 3 items for new patients or consults,
2 items for established patients
Code Level Documentation
Problem Focused: 99212, 99201 99241 One body area or system
Expanded Problem Focused: 99213,
99202, 99242 2-4 systems including affected area
Detailed: 99214, 99203, 99243 5-7 systems included affected area
99215, 99204-99205, 99244-99245 8 or more systems
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Continued from page 2
Medical Decision-Making (Also Known as Assessment and Plan) — Documentation guidelines provided by the AMA include
three criteria (diagnoses, data and risk), the two highest of which are counted toward the code level.
Risk examples include: low complexity - superficial needle biopsy; moderate complexity - undiagnosed new problem with uncertain prognosis, e.g., lump in breast or deep needle biopsy. High complexity decision-making would likely be reserved for a surgeon’s decision to perform major surgery.
Summary: If the patient has one or more lesions that could be
treated more than one way (wait, do more imaging, biopsy, surgery), had various records to review (compare old and new images, review old reports) and needed a deep needle biopsy, the decision-making would fall within low to moderate complexity overall. Then when decision making is compared with the details in the history and physical exam, the appropriate code level can be determined.
The following tables illustrate all of the key components and needed level of details to support each code.
Medical Decision Making (MDM) (2 of 3) Straightforward 99212, 99201 -9202 99241-99242 Low Complexity 99213, 99203, 99243 Moderate Complexity 99214, 99204, 00244 High Complexity 99215, 99025, 00245 A. Diagnosis / management
options Minimal (<1) Limited (2) Multiple (3)
B. Amount / complexity of
data min/Low (<1) Limited (2) Moderate (3)
C. Risk (hightet form any
category) Minimal Low Moderate High
Established Patient (Requires 2 of 3 components)
History Exam MDM Level Minimal service, RN only 99211
PF PF SF 99212
EPF EPF Low 99213
Det Det Mod 99214
Comp Comp High 99215
New Patient or Consultation (Requires 3 of 3 components)
History Exam MDM New Patient Consult
PF PF SF 99201 99241
EPF EPF SF 99202 99242
Det Det Low 99203 99243
Comp Comp Mod 99204 99244
Comp Comp High 99205 99245
Please note: the new patient or consultation code documentation is almost double that of the established patient code.
Coding is generally not based on time; however, when counseling or coordination of care dominate the encounter (either a visit or a consultation), then the required documentation criteria is waived.
However, for mammography patients, the imaging interpretations with Bi-Rads codes and/or language must be returned to the referring physician.
On the other hand, for consultations, a copy of the consultation report must be sent to the referring physician, in addition to the imaging interpretations with Bi-Rads codes and/or language if for a mammography patient.
Modifier 25 should be applied to the E&M code when it is billed on the same day as imaging or a procedure.
If the radiologist is hospital based and bills an evaluation and management code, then the hospital also may bill a facility or clinic visit, companion E&M code.
Susan Granucci, CCS-P, Healthcare Reimbursement Specialist, promotes compliance with government programs through education and internal reviews of documentation, coding and charging patterns. With more than 20 years of experience, she specializes in coverage and reimbursement rules and regulations, coding and appropriate charge capture. Contact: voice & fax 505-292-4217; e-mail: firstname.lastname@example.org.
1Source: Medicare Part B Physician/Supplier National Data, Calendar Year
2004; Evaluation and Management Codes by Specialty http://www.cms.hhs.gov/ statistics/feeforservice/em2004.pdf
2This CCI policy has been in effect for some time and remains unchanged
as of 10/1/2005.
3The full scope of E&M documentation requirements (which are too lengthy
for this article) may be obtained from http://www.cms.hhs.gov/medlearn/ emdoc.asp. Although there is much discussion on updating E&M documentation
requirements, new guidelines have yet to be finalized.
National Consortium of Breast Centers
P.O. Box 1334
Warsaw, IN 46581-1334voice: 574-267-8058 fax: 574-267-8268 email: email@example.com http://www.breastcare.org NONPROFIT ORGANIZATION U.S. POSTAGE PAID HUNTINGTON, IN PERMIT #832
Documentation should indicate time in the note; for example, code 99213 would need to reflect: Ten minutes of this 15-minute visit were spent counseling the patient on treatment options for her abnormal mammogram.
The following timetables may be used when counseling or coordination of care apply for code selection in the office or outpatient setting.
Consultation vs. Visit
A consultation is defined as a request for opinion or advice from the patient’s treating physician. The consultation may result in a decision by the consulting physician to treat or to order further tests. The consultation requires a written report to the referring physician. Again, the consultation report must be completely separate from the imaging or procedure report. If no request is made for a consult, then the visit must be coded with a new patient or established patient code.
For new or established patients, the copy of the E&M documentation does not need to be returned to the referring physician.
patient New Patient Consultation
Min. Level Min. Level Min. Level
5 99211 10 99201 15 99241
10 99212 20 99202 30 99242
15 99213 30 99203 40 99243
25 99214 45 99204 60 99244
40 99215 60 99205 80 99245
Evaluation and Management Visit Coding by Radiologists Continued from page 3