Radiology Coding Alert

Question: A radiologist in our practice recently placed a tube in a patient to drain an abscess at the request of a local surgeon because the patient had developed an infection. Our radiologist followed up with the patient in the hospital the next day, and we reported CPT 99231 for the service. However, the claim was denied. Are radiologists not allowed to bill for these follow-up visits?

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Answer: Radiologists are allowed to bill for this care as long as the visit is documented appropriately and the service performed does not have a global period. Documentation should include an assessment of the patients status and description of the services performed.

The level-one E/M code (99231, subsequent hospital care) is most often and most appropriately assigned for routine care following the placement of an abscess drainage tube. Generally, patients are stable, recovering or improving when this code is reported. Use of this code requires documentation of two of the following three components: problem-focused interval history, problem-focused exam, straightforward or low-complexity medical decision-making.

If a minor complication has developed or if the patient is not responding as expected, a level-two E/M code (99232) may be justified. In this instance, the problems being addressed are more significant and the care provided is more complex. Code 99232 includes documentation of two of the following three components: expanded problem-focused interval history, expanded problem-focused examination, and medical decision-making of moderate complexity. The corresponding level-three E/M code (99233) is seldom assigned and can be justified only for the most serious problems. Use of this code requires documentation of two of the following three components: detailed interval history, detailed examination and medical decision-making of high complexity.