In our declining reimbursement era, accurate documentation is really the only way to ensure your practice remains sustainable. Coders can only bill for what you, the rad, explicitly reports. And if it isn’t there, as Sean Golden, MD, detailed during ARRS26, you aren’t getting paid for it.
1. Moderate sedation’s magic words—most IR procedures use sedation, but you can’t simply state “moderate sedation was performed.”
- Document independent trained observer (nurse) was present, continuous monitoring occurred, you were present for first bolus, and that you spent specific face-to-face time. Reminder: it only counts as moderate if you use a combo of a benzodiazepine and an opioid.
2. Vascular US guidance is on volume—billing CPT 76937 for access might only pay ~$10, but failing to document it across a high-volume practice can cost tens of thousands annually.
- Note vessel patency, real-time visualization of needle entry, and that a permanent image was stored.
3. Don’t Forget Diagnostic Angiography! Quote often, you can bill for the diagnostic portion of a procedure if your decision to treat was based on those images.
- Log one of four of the following: no prior study available, patient’s condition changed since last study, prior study was inadequate, or clinical change occurred during procedure. [N.B. One cannot bill for simple “roadmapping.”]
4. Capture selective catheterization—In many cases, you can bill for the physical work required to get the catheter into a specific artery, in addition to the treatment code (e.g., embolization).
- Use templates that include “vessel catheterized” and “findings” sections to ensure codes are captured.
5. Add on with care…
- Cone beam CT: Record that images were sent to workstation for 3D rendering under physician supervision.
- Modifier 22: Reserve for the top 1% of difficult cases to increase reimbursement by 20-30%. Physician, prepare thyself for manual review—detailing exactly why this case was substantially harder than typical.
RadFYI: No need to reinvent the wheel here. Utilize SIR templates to automate the necessary technical and billing jargon, allowing you to keep your impression section clear and concise for both patients and referring clinicians alike.
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