Interventional radiology has evolved into a complex, wide-ranging specialty that can touch all corners of the hospital system—but that evolution has outpaced many healthcare documentation systems.
While some systems treat IR as a clinical specialty with consult-based workflows, others still classify it as radiologists working under an order-based system. This creates inconsistencies in how procedures are managed and billed, often resulting in additional administrative work for IRs and missed opportunities for reimbursement.
“Epic really keeps IR to its roots of radiology, and treats us like one of the radiology subspecialties,” said Sebouh A. Gueyikian, MD. Dr. Gueyikian, a member of the Association of Chiefs in Interventional Radiology, spoke on the challenges of capturing evaluation and management (E/M) revenue at the fall ACIR meeting.
According to Dr. Gueyikian, most IR services are utilizing systems optimized for radiology, where every single action is considered a billable encounter. However, that is not the case for IR—especially when it comes to evaluation and management coding.
Capturing your work
Most facilities use Epic, which is meant to be the global place where all physicians interact, and which automatically captures the billing for those interactions. But a lot of evaluation and management work happens outside of Epic, and Dr. Gueyikian wants IRs to know they can capture that, as well.
Because IR is at the intersection of radiology, minimally invasive procedures, and the clinical realm, IRs receive a huge number of requests for second opinions, recommendations or report interpretations. Because that work wasn’t captured in Epic, a physician could be asked about the same patient multiple times from different services.
Additionally, many referrals do not actually result in procedures—but it takes time for IRs to determine that.
“We can spend 10-15 minutes looking through a chart before realizing the patient isn’t a good candidate for IR therapy. That’s 10-15 minutes of your time lost, and there are some IRs who simply do not have the time to look at requests or evaluate new patients, because it is so time consuming, and there’s no reimbursement,” Dr. Gueyikian said.
So, the question is, how do you convert that work into something that is documented, as well as billable?
Learning the codes
Historically, an IR consult would involve meeting the patient in person to discuss a treatment plan. This workflow is well-established and has a billable code. However, hospitals are increasingly dealing with patients that are spread across large geographic areas, and there aren’t enough IRs to meet the demand for in-person consults.
“Now, you are seeing the virtual representation of the patient, which is their chart,” Dr. Gueyikian said. “You can get almost all the information you need from a chart, without meeting the patient. That didn’t used to be billable work, but now it is.”
There are now specific code sets that help IRs and other clinical physicians capture E/M work that happens in a virtual space.
“There are rules around them,” Dr. Gueyikian said. “You must have the patient’s permission for telemedicine work, for example, and you cannot use certain codes multiple times within a certain period of time for the same patient. And if you’re going to do a procedure on this patient, you may not be able to collect on certain codes because you’ll be seeing them in-person within a week.”
Learning these codes is difficult, especially as many IRs were not taught about E/M billing during their training. Finding reputable, IR-focused resources can also be a challenge, which is why many IRs are forced to learn on the job.
Dr. Gueyikian said most of his on-the-job training has come from resources provided by SIR, such as the Coding Academy or the SIR Business Institute. But he has also learned a lot from other specialties who are better versed in capturing this work.
“Speaking to my colleagues in other specialties has been extremely eye-opening,” he said. “I realized that the tools they use in Epic have been built specifically for them, and it makes this work so much easier if you can find a way for those tools to be brought into your Epic world.”
Optimizing your system
According to Dr. Gueyikian, the fact that IR is a “hybrid specialty” that does both consults and clinical work makes it difficult for many systems to have an out-of-thse-box solution, and there is a lot of manual work that has to be done to optimize Epic for IR in terms of appointment schedules, clinic visits and E/M coding.
“If you’re lucky to have an IR chief, they can commit some administrative time optimizing Epic. Otherwise, each individual IR physician must spend human time doing computer work,” Dr. Gueyikian said.
However, there are hundreds of home-grown workflows in Epic—many of which may be in use in a different department at an IR’s home institution.
Dr. Gueyikian has built a series of templates himself, which feature pre-built notes that will automatically pull in patient information and generate the note. Each template is designed to ensure information is captured and associated with the correct code, so that his partners wouldn’t need to worry if they were missing out on something crucial for reimbursement.
“There is always a fear that you’ve forgotten the magic phrase to collect reimbursement,” Dr. Gueyikian said. “So, as part of our audit review with our billing company, we submitted several of these reports to see if they were billing correctly, and they were.”
Selecting an appropriate billing service is also crucial, Dr. Gueyikian said, as traditional radiology billing companies are not often well versed in E/M coding.
“One solution is to have part of your volume go through a radiology billing company but have the E/M coding go through a clinically based billing company,” he said.
It can be a challenge to relearn a new way to use Epic, especially for those who have been using it for decades. But Dr. Gueyikian believes that the effort is all worth it.
“If you can properly utilize the codes and technology at your disposal, it means you will have better documentation, reliable reimbursement, and more time available to dedicate to patient care.”
