June 30, 2012

ACR Radiology Coding Source™ May-June 2012 Q and A

Q: Can a radiologist in an office setting bill an evaluation and management service in conjunction with a breast MRI procedure (77058, 77059) when the radiologist reviews the findings with the patient?

A: No, a radiologist should not report an evaluation and management (E/M) code when the findings of a breast MRI procedure are discussed with the patient, whether it be in an office or any other setting. Discussing the findings of a diagnostic procedure with the referring physician and/or patient is considered part of the diagnostic procedure. 

Radiation oncology and nuclear medicine practices commonly report E/M services, while the vast majority of E/M services in diagnostic radiology occur within the area of interventional procedures. See the January/February 2008 ACR Radiology Coding Source for a discussion of the reporting of E/M services in interventional radiology. 

Q: Where can I find the most current evaluation and management guidelines?

A: The latest evaluation and management (E/M) guidelines are posted on the Centers for Medicare and Medicaid Services website under the Medicare Learning Network, Documentation Guidelines for Evaluation and Management (E/M) Services. Note that providers may use either the 1995 or 1997 version of the documentation guidelines, but not a combination of the two, for a patient encounter.