Radiology Coding Alert

Reader Question:

Arteriogram Related to Short Stay Care

Question: What S & I (supervision & interpretation) code should I charge for a procedure related to short stay care (outpatient observation)? For instance, an arteriogram for which the patient stays six hours and I write a history and physical.

Dr. Eiland
Helen Ellis Memorial Hospital
Tarpon Springs, Fla.

Answer: When a patient is in observation after a procedure has been performed, the creation of documentation required by the hospital is included in the fee for the procedure and would not be billed separately. However, if the procedure was not planned, and an evaluation of the patient was necessary to determine the need for the procedure, a separate evaluation and management service could be billed using the codes for observation (99234-99236).

Source for answers: Susan Callaway-Stradley, CPC, CCS-P,an independent coding consultant and educator based in North Augusta, S.C.