A: It is only appropriate to bill for a consultation or other evaluation and management (E/M) service when the service is provided and documented according to established E/M guidelines. For breast interventional procedures, a brief review of history and physical exam and obtaining informed consent is not a separately reportable E/M service. This service is considered bundled into the surgical procedure code.
Click here for a copy of the documentation guidelines. The E/M guidelines are currently under review. Until the E/M documentation guidelines are finalized, it is up to the provider to use either the 1995 or 1997 published guidelines. It is recommended, however, that for auditing purposes a radiology practice use one set of guidelines, ie, either 1995 or 1997.