- Email: [email protected]
Clinical Services Provided by Interventional Radiologists to Medicare Beneficiaries in the United States, 2000-2003
Clinical Services Provided by Interventional Radiologists to Medicare Beneficiaries in the United States, 2000-2003 Nadir Khan, MD,1 Timothy P. Murphy, MD, Gregory M. Soares, MD, and Ismail S. Zahir, MD
To identify trends in Evaluation and Management (E&M) and non-E&M services of interventional radiologists (physician specialty type 94) from 2000 to 2003 for Medicare patients, Medicare Part B physician annual allowed services data from the Centers of Medicare and Medicaid Services (CMS) were analyzed for all interventional radiologists from 2000 to 2003. Because the number of interventional radiologists in the United States according to the Society of Interventional Radiology is, on average, 4.2 times the number of interventional radiologists who use physician specialty type 94, we extrapolated the E&M services for each year. During the period examined, the total number of E&M services by interventional radiologists increased 309%, from 9,698 in 2000 to 29,914 in 2003. The most commonly performed services were Office or Other Outpatient Visit (Current Procedural Terminology [CPT] codes 99211–99215) for established patients, followed by Subsequent Hospital Care (CPT 99231–99233) and Office or Other Outpatient Consultations (CPT 99241–99245). The extrapolated number of E&M services by interventional radiologists for Medicare patients in 2003 is approximately 107,853. The number of Office and Outpatient Visits for New Patients (CPT 99201–99205) increased 142%, whereas the number of Consultations for New Patients (CPT 99241–99245) increased 208%. The total number of codes reimbursed by CMS to interventional radiologists (type 94) increased from 2.8 million in 2000 to 3.8 million in 2003. J Vasc Interv Radiol 2005; 16:1753–1757 Abbreviations: CMS ⫽ Centers for Medicare and Medicaid Services, CPT ⫽ Current Procedure Terminology, E&M ⫽ Evaluation and Management
TO date, several publications have confirmed the need for clinical services and direct patient care on the part of interventional radiologists (1–3). In May 2003, the American College of Radiology published a White Paper (“Current Status, Guidelines for Resource Allocation and Future Direction”) that recognized the importance of the clinical practice of interventional radiology (4). From the Division of Vascular and Interventional Radiology, Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02903. Received April 14, 2005; accepted August 18. Address correspondence to T.P.M.; E-mail: [email protected] 1 Current address: Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY.
None of the authors have identified a conflict of interest. © SIR, 2005 DOI: 10.1097/01.RVI.0000184532.58717.F5
The results of the 2000 –2001 Socioeconomics Survey by the Society of Interventional Radiology (SIR) showed that 92% of interventional radiologists perform hospital rounds after procedure and hospital consultations (5). In contrast, Mabry and Duszak (6) showed in 2003, with data from the National Medicare Database (1997–2000), that interventional radiologists had increased Evaluation and Management (E&M) services by only 2%. The goal of this analysis is to identify trends in E&M and non-E&M services by looking at the Current Procedural Terminology (CPT) codes for interventional radiologists from 2000 to 2003.
MATERIALS AND METHODS Information was obtained from 2000 –2003 Medicare Part B Physician annual utilization data from the Centers for Medicare and Medicaid Services (CMS) (7). These data include all
claims paid by CMS, and include data on each CPT code submitted that was reimbursed. This information is available as part of Medicare Part A and Part B E&M Codes by Specialty that can used by the public. This data are in raw format on Excel (Microsoft, Redmond, WA). Similar information has been used previously (8 –10). The data for 2003, at the time of this writing, were not available online and were subsequently obtained via e-mail through direct correspondence with CMS. The Medicare Physician Registry by Specialty (2001–2003) data were obtained from the online version of the annual data Compendium published by the CMS and gives key statistics about its programs and health care spending (11). Because the number of interventional radiologists recorded by CMS as physician specialty type 94 was substantially lower than the number of members of SIR, the largest U.S. organization of interven-
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Table 1 Extrapolated Absolute Numbers of E&M Services for Each Year CMS Data Total no. of interventional radiologists Total services by interventional radiologists (physician specialty type 94) No. of services by each interventional radiologist (physician specialty type 94) Total US members of SIR SIR members/physician specialty type 94 Physicians CMS data Extrapolated no. of services by all interventional radiologists
2001
2002
2003
639 11,514
652 18,250
811 29,914
18
28
37
2,852 4.5
2,853 4.4
2,924 3.6
51,390
79,858
107,853
Note.—Because the number of interventional radiologists who are US members of SIR is 4.2 times the number of interventional radiologists who use physician specialty type 94, we used the number of US members of SIR from 2001 to 2003 to extrapolate the absolute number of E&M services performed by interventional radiologists in the United States by inflating the number of interventional radiologists reported by CMS from 2001 to 2003 by a factor of the entire active US membership of SIR divided by the number of providers designated as physician specialty type 94 for CMS for the same years.
tional radiologists, we also obtained the number of US members of SIR for years 2001, 2002, and 2003 (Joy Gornal, written communication, April 2005) and used this number divided by the number of physicians designating themselves as specialty type 94 for CMS as a factor by which we could inflate the numbers to provide an estimate of the absolute number of E&M services provided by interventional radiologists to Medicare patients (Table 1). This inflation assumes that the rate of reimbursement of interventional radiologists (type 94) is similar to that of SIR members who designate themselves as another specialty type (for example, type 30 for Diagnostic Radiology). There is no reasonable way for us to verify that assumption. CMS requires all physician claims for reimbursement to include specific CPT codes to describe the services provided in addition to identifying their specialty or subspecialty codes. The raw data are prescreened and edited by CMS to comply with their privacy guidelines before being made publicly available. With use of Excel software (Microsoft), information pertaining to CMS specialty type 94 (Interventional Radiology) was extracted and evaluated. We looked at the number of E&M and non–E&M services from 2000 to 2003 for interventional radiologists (type 94; Table 2). The number
of E&M services as a percentage of all services was calculated for each year. The E&M services by interventional radiologists were further evaluated according to the CPT service type and the individual E&M CPT services (Tables 3, 4). Further evaluation of E&M CPT codes 99201–99205 (New Patient E&M services provided in the physician’s office or in an outpatient or other ambulatory facility) and 99241– 99245 (New or Established patient E&M consultation encounters provided in the physician’s office or in an outpatient or other ambulatory facility, including hospital services, domiciliary, rest home, custodial care, or emergency department) gave us a more in-depth analysis of referrals for new patients (Table 3). We also examined total codes reimbursed by Medicare, including E&M, surgical, and radiologic supervision and interpretation codes to look for changes over time.
RESULTS Interventional Radiologists The number of E&M services by interventional radiologists increased 309%, from 9,698 services in 2000 to 29,914 services in 2003 (Fig 1). There was an increase of 119% from 2000 to 2001, a 159% increase from 2001 to 2002, and a 164% increase from 2002 to
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2003. During the same period, the non–E&M services (imaging services, surgical procedural services, and radiologic services) by interventional radiologists also increased by 136%, from 2.78 million in 2000 to 3.77 million in 2003 (Table 2). Looking at the E&M services as a percentage of all services (E&M and non–E&M) provided by interventional radiologists, E&M services increased substantially from 0.35% to 0.79%. Although a relatively small proportion, E&M services usually consist of only one reimbursable code per day, whereas procedures usually entail at least two codes per encounter and often more. The Medicare Physician Registry by Specialty showed an increase from 639 interventional radiologists in January 2001 to 811 in April 2003, a total increase of 172 (27%). The number of interventional radiologists who are US members of SIR are, on average, 4.2 times the number of interventional radiologists who use Physician Specialty code 94 for E&M CPT coding (Table 1). It is likely that many interventional radiologists register with CMS with use of Specialty Code 30 used by diagnostic radiologists. We extrapolated the absolute number of E&M codes reimbursed to interventional radiologists in the United States by multiplying by a factor derived by dividing the number of SIR members by the number registered with CMS as specialty type 94. This assumes that interventional radiologists who register with CMS as specialty type 94 have similar patterns in performance of E&M services as those who use another specialty type. It is not known if that is true, and there are valid reasons why this may over- or underestimate the number of E&M services performed by interventional radiologists in the United States. With use of these methods, we estimate the total number of E&M services done by interventional radiologists in the US in each of the 3 years as 51,390 E&M services performed in 2001, 79,858 in 2002, and 107,853 in 2003 (Table 1). Of course, not all health care services are reimbursed under the Medicare program and these numbers may underestimate the amount of evaluation and management services performed by interventional radiologists considerably, perhaps by a factor of two.
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Table 2 All Services by Interventional Radiologists and Diagnostic Radiologists per CMS Data Year Interventional Radiologists (specialty type 94)
2000
2001
2002
2003
E&M services Non–E&M services All services Percentage of E&M services among all services
9,698 2,775,858 2,785,556 0.35
11,514 2,752,296 2,763,810 0.42
18,250 3,233,727 3,251,977 0.56
29,914 3,770,130 3,800,044 0.79
Table 3 Most Commonly Used E&M Services for Interventional Radiologists Rank
CPT Code
Descriptor
2000
2001
2002
2003
Increase (%)
1 2 3 4 5 6 7 8
99211–99215 99231–99233 99241–99245 99251–99255 99261–99263 99281–99285 99201–99205 99221–99223
Office or Other Outpatient services for Established Patients Hospital Inpatient: Subsequent Hospital Care Office or Other Outpatient Consultations Initial Inpatient Consultations Follow-up Inpatient Consultations Emergency Department Services Office or Other Outpatient services, New Patients Hospital Inpatient: Initial Hospital Care
3314 1237 1824 658 660 225 673 178
3037 2017 1864 1105 1359 650 761 146
5356 3797 2999 1633 1509 1333 633 319
12761 5880 4245 1888 1109 1450 910 614
385 475 233 287 168 644 135 345
Table 4 Greatest Increase in E&M Services by Interventional Radiologists Rank
CPT Code
Descriptor (Time)
2000
2001
2002
2003
Increase (%)
1 2 3 4 5 6 7 8 9 10
99223 99232 99214 99285 99284 99283 99215 99255 99254 99211
Initial Hospital care (70 min) Subsequent Hospital Care (25 min) Office or Other Outpatient Visit (25 min) Emergency Department Visit Emergency Department Visit Emergency Department Visit Office or Other Outpatient Visit (40 min) Initial Inpatient Consultation (110 min) Initial Inpatient Consultation (80 min) Office or Other Outpatient Visit (5 min)
13 252 284 49 88 59 50 45 99 297
36 597 162 199 268 155 55 33 105 194
168 1,453 846 380 498 366 192 91 298 402
442 2,427 2,642 371 640 373 284 230 470 1,329
3,400 963 930 757 727 632 568 511 475 448
Interventional Radiology E&M Services Frequency Distribution We evaluated the E&M services for CPT codes 99201–99499 for interventional radiologists (type 94), examining the eight most commonly used E&M services in 2000 –2003. Of these, the most commonly used E&M service, Office or Other Outpatient services (CPT 99211–99215) for Established Patients, increased 385% (Table 3). We also evaluated the individual CPT codes that had the highest percentage increases in services. Overall, the highest increase occurred in highcomplexity services (CPT codes 99233,
99285, 99215, and 99255), of which Initial Hospital care (CPT 99233) for 70 minutes of face-to-face time spent with the patient and/or family increased most. Finally, we took a closer look at CPT codes 99201–99205 (Office or Other Outpatient Visits) and CPT codes 99241–99245 (Consultations) by interventional radiologists (Fig 2). Although increases occurred in all Office or Other Outpatient encounters for New Patients except for CPT code 99202 (20 minutes), which decreased by 124%, the absolute numbers are not very high. The highest increase of
287% occurred in CPT code 99205, which requires 60 minutes face-to-face with the patient and/or family with a medical decision of high complexity. Analysis of Office Consultations (CPT 99241–99245) for a New or Established Patient showed increases in all CPT codes. Of these codes, the highest volumes, in CPT codes 99244 and 99243, increased by 201% and 173%, respectively.
DISCUSSION Numerous leaders in interventional radiology have noted the essential na-
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Figure 1. E&M services provided to Medicare beneficiaries by interventional radiologists from 2000 to 2003. The chart shows an increase of 20,216 (209%) E&M services, from 9,698 in 2000 to 29,914 in 2003.
Figure 2. CPT codes 99201–99205 represent office or other outpatient services for new patients. CPT codes 99241–99245 represent consultations for new or established patients. All show an increase in services except for Code CPT 99202.
ture of clinical care when performing therapeutic interventions and called on their colleagues to embrace longitudinal patient contact and patient evaluation and management (1– 4), extending back to Charles Dotter (12). Our review of CMS data indicates that, recently, interventional radiologists have increased their E&M and non–E&M services 309% and 136%, respectively (Table 1). This is a substantial increase, in contrast to the data shown by Mabry and Duszak (6) from 1997 to 2000 when E&M and non– E&M services increased by 2% and
10.7%, respectively. Although CMS data showed 29,914 E&M services in 2003, our extrapolated data to the entire membership of the SIR yielded an estimate of 107,853 E&M services for the same year, which may actually be less than half the actual amount when non-CMS payers are considered (Table 2). Additionally, a small number of follow-up services performed may not be captured because those performed during a global period are not reimbursable. For all practical purposes, this would include only tunneled catheter or port placement or biliary drain-
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age and are not expected to significantly impact the overall results of this analysis. Although the exact number of E&M services provided by interventional radiologists in the US is difficult to elucidate for many reasons, it is clear that interventional radiologists are rapidly incorporating patient evaluation and management into their practices. Interventional radiologists have shown great increases in all types of services including Initial Inpatient Care, Subsequent Hospital Care, Office and Outpatient Visits, Consultations, and Emergency Department Visits (Table 3). Although the most commonly performed procedures are low-complexity services such as CPT 99213 and 99231, the 10 greatest increases in services occurred in highand moderate-complexity services, such as CPT 99233 (Initial Hospital Care), CPT 99232 (Subsequent Hospital Care), CPT 99214 (Office or Other Outpatient Visit), and CPT 99285 (Emergency Department Visit; Table 4). Looking at the increase in CPT codes 99223 (70 minutes), 99255 (110 minutes) and 99254 (80 minutes), it shows an interesting aspect of increased face-to-face time spent with the patients and/or family during evaluation and/or management services by interventional radiologists. The number of E&M services on average reimbursed to each interventional radiologist by CMS doubled from 2001 to 2003 (Table 2). Our review of CMS data from 2000 to 2003 has shown a major shift from the data reported by Mabry and Duszak (6) from 1997 to 2000, which suggested marginal growth in patient evaluation and management by interventional radiologists. The annual increase in E&M codes paid by Medicare to interventional radiologists (physician specialty type 94) increased most dramatically in 2002 (59%) and 2003 (64%). The most rapid growth in overall services reimbursed to interventional radiologists by Medicare mirrors the periods of growth in clinical services reimbursed. The total number of codes paid by Medicare to interventional radiologists increased from 2.8 million in 2001 to 3.3 million in 2002 (17% annual growth) and to 3.8 million in 2003 (17% annual growth). Interventional radiology is a specialty that is becoming increasingly clinical and demonstrating strong overall growth.
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References 1. Katzen BT, Kaplan JO, Dake MD. Developing an interventional radiology practice in a community hospital: the interventional radiologist as an equal partner in patient care. Radiology 1989; 170:955–958. 2. Barth KH, Matsumoto AH. Patient care in interventional radiology: a perspective. Radiology 1991; 178:11–17. 3. Murphy TP. Interventional radiology: a call to arms. J Vasc Interv Radiol 1999; 10:377–378. 4. Pentecost MJ. American College of Radiology: Clinical Practice of Interventional Radiology and Neurointerventional Radiology White Paper, May 2003. Reston, VA: ACR, 2003. 5. Levin DC, Parker L,Eschelman DJ.
Khan et al
Society of Cardiovascular and Interventional Radiology 2000 –2001 SCVIR Socioeconomics Survey. Fairfax, VA: SCVIR, 2002. 6. Duszak Jr, R Mabry MR. Clinical services in interventional radiology: results from the national Medicare database and a Society of Interventional Radiology membership survey. J Vasc Interv Radiol 2003; 14:75–81. 7. Centers for Medicare and Medicaid Services. Medicare fee-for-service. Available at: http://www.cms.hhs. gov/statistics/feeforservice. Accessed: February 1, 2005. 8. Rao VM, Levin DC, Spettell CM, et al. Who performs neuroimaging? Results from the 1993 National Medicare Database. Radiology 1997; 204:443–445.
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9. Livstone VJ, Parker L, Levin DC. Trends in the utilization of MR angiography and body MR imaging in the U.S. Medicare population: 1993–1998. Radiology 2002; 222:615–618. 10. Maitino AJ, Levin DC, Parker L, et al. Practice patterns of radiologists and non-radiologists in utilization of noninvasive diagnostic imaging among the Medicare population 1993-1999. Radiology 2003; 228:795–801. 11. Centers for Medicare and Medicaid Services. Medicare Physician Registry by Specialty. Available at: www. cms.hhs.gov / researchers / pubs/ datacompendium. Accessed February 1, 2005. 12. Dotter CT. Transluminal angioplasty. AJR Am J Roentgenol 1980; 135:997–998.
To identify trends in Evaluation and Management (E&M) and non-E&M services of interventional radiologists (physician specialty type 94) from 2000 to 2003 for Medicare patients, Medicare Part B physician annual allowed services data from the Centers of Medicare and Medicaid Services (CMS) were analyzed for all interventional radiologists from 2000 to 2003. Because the number of interventional radiologists in the United States according to the Society of Interventional Radiology is, on average, 4.2 times the number of interventional radiologists who use physician specialty type 94, we extrapolated the E&M services for each year. During the period examined, the total number of E&M services by interventional radiologists increased 309%, from 9,698 in 2000 to 29,914 in 2003. The most commonly performed services were Office or Other Outpatient Visit (Current Procedural Terminology [CPT] codes 99211–99215) for established patients, followed by Subsequent Hospital Care (CPT 99231–99233) and Office or Other Outpatient Consultations (CPT 99241–99245). The extrapolated number of E&M services by interventional radiologists for Medicare patients in 2003 is approximately 107,853. The number of Office and Outpatient Visits for New Patients (CPT 99201–99205) increased 142%, whereas the number of Consultations for New Patients (CPT 99241–99245) increased 208%. The total number of codes reimbursed by CMS to interventional radiologists (type 94) increased from 2.8 million in 2000 to 3.8 million in 2003. J Vasc Interv Radiol 2005; 16:1753–1757 Abbreviations: CMS ⫽ Centers for Medicare and Medicaid Services, CPT ⫽ Current Procedure Terminology, E&M ⫽ Evaluation and Management
TO date, several publications have confirmed the need for clinical services and direct patient care on the part of interventional radiologists (1–3). In May 2003, the American College of Radiology published a White Paper (“Current Status, Guidelines for Resource Allocation and Future Direction”) that recognized the importance of the clinical practice of interventional radiology (4). From the Division of Vascular and Interventional Radiology, Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02903. Received April 14, 2005; accepted August 18. Address correspondence to T.P.M.; E-mail: [email protected] 1 Current address: Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY.
None of the authors have identified a conflict of interest. © SIR, 2005 DOI: 10.1097/01.RVI.0000184532.58717.F5
The results of the 2000 –2001 Socioeconomics Survey by the Society of Interventional Radiology (SIR) showed that 92% of interventional radiologists perform hospital rounds after procedure and hospital consultations (5). In contrast, Mabry and Duszak (6) showed in 2003, with data from the National Medicare Database (1997–2000), that interventional radiologists had increased Evaluation and Management (E&M) services by only 2%. The goal of this analysis is to identify trends in E&M and non-E&M services by looking at the Current Procedural Terminology (CPT) codes for interventional radiologists from 2000 to 2003.
MATERIALS AND METHODS Information was obtained from 2000 –2003 Medicare Part B Physician annual utilization data from the Centers for Medicare and Medicaid Services (CMS) (7). These data include all
claims paid by CMS, and include data on each CPT code submitted that was reimbursed. This information is available as part of Medicare Part A and Part B E&M Codes by Specialty that can used by the public. This data are in raw format on Excel (Microsoft, Redmond, WA). Similar information has been used previously (8 –10). The data for 2003, at the time of this writing, were not available online and were subsequently obtained via e-mail through direct correspondence with CMS. The Medicare Physician Registry by Specialty (2001–2003) data were obtained from the online version of the annual data Compendium published by the CMS and gives key statistics about its programs and health care spending (11). Because the number of interventional radiologists recorded by CMS as physician specialty type 94 was substantially lower than the number of members of SIR, the largest U.S. organization of interven-
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Table 1 Extrapolated Absolute Numbers of E&M Services for Each Year CMS Data Total no. of interventional radiologists Total services by interventional radiologists (physician specialty type 94) No. of services by each interventional radiologist (physician specialty type 94) Total US members of SIR SIR members/physician specialty type 94 Physicians CMS data Extrapolated no. of services by all interventional radiologists
2001
2002
2003
639 11,514
652 18,250
811 29,914
18
28
37
2,852 4.5
2,853 4.4
2,924 3.6
51,390
79,858
107,853
Note.—Because the number of interventional radiologists who are US members of SIR is 4.2 times the number of interventional radiologists who use physician specialty type 94, we used the number of US members of SIR from 2001 to 2003 to extrapolate the absolute number of E&M services performed by interventional radiologists in the United States by inflating the number of interventional radiologists reported by CMS from 2001 to 2003 by a factor of the entire active US membership of SIR divided by the number of providers designated as physician specialty type 94 for CMS for the same years.
tional radiologists, we also obtained the number of US members of SIR for years 2001, 2002, and 2003 (Joy Gornal, written communication, April 2005) and used this number divided by the number of physicians designating themselves as specialty type 94 for CMS as a factor by which we could inflate the numbers to provide an estimate of the absolute number of E&M services provided by interventional radiologists to Medicare patients (Table 1). This inflation assumes that the rate of reimbursement of interventional radiologists (type 94) is similar to that of SIR members who designate themselves as another specialty type (for example, type 30 for Diagnostic Radiology). There is no reasonable way for us to verify that assumption. CMS requires all physician claims for reimbursement to include specific CPT codes to describe the services provided in addition to identifying their specialty or subspecialty codes. The raw data are prescreened and edited by CMS to comply with their privacy guidelines before being made publicly available. With use of Excel software (Microsoft), information pertaining to CMS specialty type 94 (Interventional Radiology) was extracted and evaluated. We looked at the number of E&M and non–E&M services from 2000 to 2003 for interventional radiologists (type 94; Table 2). The number
of E&M services as a percentage of all services was calculated for each year. The E&M services by interventional radiologists were further evaluated according to the CPT service type and the individual E&M CPT services (Tables 3, 4). Further evaluation of E&M CPT codes 99201–99205 (New Patient E&M services provided in the physician’s office or in an outpatient or other ambulatory facility) and 99241– 99245 (New or Established patient E&M consultation encounters provided in the physician’s office or in an outpatient or other ambulatory facility, including hospital services, domiciliary, rest home, custodial care, or emergency department) gave us a more in-depth analysis of referrals for new patients (Table 3). We also examined total codes reimbursed by Medicare, including E&M, surgical, and radiologic supervision and interpretation codes to look for changes over time.
RESULTS Interventional Radiologists The number of E&M services by interventional radiologists increased 309%, from 9,698 services in 2000 to 29,914 services in 2003 (Fig 1). There was an increase of 119% from 2000 to 2001, a 159% increase from 2001 to 2002, and a 164% increase from 2002 to
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2003. During the same period, the non–E&M services (imaging services, surgical procedural services, and radiologic services) by interventional radiologists also increased by 136%, from 2.78 million in 2000 to 3.77 million in 2003 (Table 2). Looking at the E&M services as a percentage of all services (E&M and non–E&M) provided by interventional radiologists, E&M services increased substantially from 0.35% to 0.79%. Although a relatively small proportion, E&M services usually consist of only one reimbursable code per day, whereas procedures usually entail at least two codes per encounter and often more. The Medicare Physician Registry by Specialty showed an increase from 639 interventional radiologists in January 2001 to 811 in April 2003, a total increase of 172 (27%). The number of interventional radiologists who are US members of SIR are, on average, 4.2 times the number of interventional radiologists who use Physician Specialty code 94 for E&M CPT coding (Table 1). It is likely that many interventional radiologists register with CMS with use of Specialty Code 30 used by diagnostic radiologists. We extrapolated the absolute number of E&M codes reimbursed to interventional radiologists in the United States by multiplying by a factor derived by dividing the number of SIR members by the number registered with CMS as specialty type 94. This assumes that interventional radiologists who register with CMS as specialty type 94 have similar patterns in performance of E&M services as those who use another specialty type. It is not known if that is true, and there are valid reasons why this may over- or underestimate the number of E&M services performed by interventional radiologists in the United States. With use of these methods, we estimate the total number of E&M services done by interventional radiologists in the US in each of the 3 years as 51,390 E&M services performed in 2001, 79,858 in 2002, and 107,853 in 2003 (Table 1). Of course, not all health care services are reimbursed under the Medicare program and these numbers may underestimate the amount of evaluation and management services performed by interventional radiologists considerably, perhaps by a factor of two.
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Table 2 All Services by Interventional Radiologists and Diagnostic Radiologists per CMS Data Year Interventional Radiologists (specialty type 94)
2000
2001
2002
2003
E&M services Non–E&M services All services Percentage of E&M services among all services
9,698 2,775,858 2,785,556 0.35
11,514 2,752,296 2,763,810 0.42
18,250 3,233,727 3,251,977 0.56
29,914 3,770,130 3,800,044 0.79
Table 3 Most Commonly Used E&M Services for Interventional Radiologists Rank
CPT Code
Descriptor
2000
2001
2002
2003
Increase (%)
1 2 3 4 5 6 7 8
99211–99215 99231–99233 99241–99245 99251–99255 99261–99263 99281–99285 99201–99205 99221–99223
Office or Other Outpatient services for Established Patients Hospital Inpatient: Subsequent Hospital Care Office or Other Outpatient Consultations Initial Inpatient Consultations Follow-up Inpatient Consultations Emergency Department Services Office or Other Outpatient services, New Patients Hospital Inpatient: Initial Hospital Care
3314 1237 1824 658 660 225 673 178
3037 2017 1864 1105 1359 650 761 146
5356 3797 2999 1633 1509 1333 633 319
12761 5880 4245 1888 1109 1450 910 614
385 475 233 287 168 644 135 345
Table 4 Greatest Increase in E&M Services by Interventional Radiologists Rank
CPT Code
Descriptor (Time)
2000
2001
2002
2003
Increase (%)
1 2 3 4 5 6 7 8 9 10
99223 99232 99214 99285 99284 99283 99215 99255 99254 99211
Initial Hospital care (70 min) Subsequent Hospital Care (25 min) Office or Other Outpatient Visit (25 min) Emergency Department Visit Emergency Department Visit Emergency Department Visit Office or Other Outpatient Visit (40 min) Initial Inpatient Consultation (110 min) Initial Inpatient Consultation (80 min) Office or Other Outpatient Visit (5 min)
13 252 284 49 88 59 50 45 99 297
36 597 162 199 268 155 55 33 105 194
168 1,453 846 380 498 366 192 91 298 402
442 2,427 2,642 371 640 373 284 230 470 1,329
3,400 963 930 757 727 632 568 511 475 448
Interventional Radiology E&M Services Frequency Distribution We evaluated the E&M services for CPT codes 99201–99499 for interventional radiologists (type 94), examining the eight most commonly used E&M services in 2000 –2003. Of these, the most commonly used E&M service, Office or Other Outpatient services (CPT 99211–99215) for Established Patients, increased 385% (Table 3). We also evaluated the individual CPT codes that had the highest percentage increases in services. Overall, the highest increase occurred in highcomplexity services (CPT codes 99233,
99285, 99215, and 99255), of which Initial Hospital care (CPT 99233) for 70 minutes of face-to-face time spent with the patient and/or family increased most. Finally, we took a closer look at CPT codes 99201–99205 (Office or Other Outpatient Visits) and CPT codes 99241–99245 (Consultations) by interventional radiologists (Fig 2). Although increases occurred in all Office or Other Outpatient encounters for New Patients except for CPT code 99202 (20 minutes), which decreased by 124%, the absolute numbers are not very high. The highest increase of
287% occurred in CPT code 99205, which requires 60 minutes face-to-face with the patient and/or family with a medical decision of high complexity. Analysis of Office Consultations (CPT 99241–99245) for a New or Established Patient showed increases in all CPT codes. Of these codes, the highest volumes, in CPT codes 99244 and 99243, increased by 201% and 173%, respectively.
DISCUSSION Numerous leaders in interventional radiology have noted the essential na-
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Figure 1. E&M services provided to Medicare beneficiaries by interventional radiologists from 2000 to 2003. The chart shows an increase of 20,216 (209%) E&M services, from 9,698 in 2000 to 29,914 in 2003.
Figure 2. CPT codes 99201–99205 represent office or other outpatient services for new patients. CPT codes 99241–99245 represent consultations for new or established patients. All show an increase in services except for Code CPT 99202.
ture of clinical care when performing therapeutic interventions and called on their colleagues to embrace longitudinal patient contact and patient evaluation and management (1– 4), extending back to Charles Dotter (12). Our review of CMS data indicates that, recently, interventional radiologists have increased their E&M and non–E&M services 309% and 136%, respectively (Table 1). This is a substantial increase, in contrast to the data shown by Mabry and Duszak (6) from 1997 to 2000 when E&M and non– E&M services increased by 2% and
10.7%, respectively. Although CMS data showed 29,914 E&M services in 2003, our extrapolated data to the entire membership of the SIR yielded an estimate of 107,853 E&M services for the same year, which may actually be less than half the actual amount when non-CMS payers are considered (Table 2). Additionally, a small number of follow-up services performed may not be captured because those performed during a global period are not reimbursable. For all practical purposes, this would include only tunneled catheter or port placement or biliary drain-
December 2005
JVIR
age and are not expected to significantly impact the overall results of this analysis. Although the exact number of E&M services provided by interventional radiologists in the US is difficult to elucidate for many reasons, it is clear that interventional radiologists are rapidly incorporating patient evaluation and management into their practices. Interventional radiologists have shown great increases in all types of services including Initial Inpatient Care, Subsequent Hospital Care, Office and Outpatient Visits, Consultations, and Emergency Department Visits (Table 3). Although the most commonly performed procedures are low-complexity services such as CPT 99213 and 99231, the 10 greatest increases in services occurred in highand moderate-complexity services, such as CPT 99233 (Initial Hospital Care), CPT 99232 (Subsequent Hospital Care), CPT 99214 (Office or Other Outpatient Visit), and CPT 99285 (Emergency Department Visit; Table 4). Looking at the increase in CPT codes 99223 (70 minutes), 99255 (110 minutes) and 99254 (80 minutes), it shows an interesting aspect of increased face-to-face time spent with the patients and/or family during evaluation and/or management services by interventional radiologists. The number of E&M services on average reimbursed to each interventional radiologist by CMS doubled from 2001 to 2003 (Table 2). Our review of CMS data from 2000 to 2003 has shown a major shift from the data reported by Mabry and Duszak (6) from 1997 to 2000, which suggested marginal growth in patient evaluation and management by interventional radiologists. The annual increase in E&M codes paid by Medicare to interventional radiologists (physician specialty type 94) increased most dramatically in 2002 (59%) and 2003 (64%). The most rapid growth in overall services reimbursed to interventional radiologists by Medicare mirrors the periods of growth in clinical services reimbursed. The total number of codes paid by Medicare to interventional radiologists increased from 2.8 million in 2001 to 3.3 million in 2002 (17% annual growth) and to 3.8 million in 2003 (17% annual growth). Interventional radiology is a specialty that is becoming increasingly clinical and demonstrating strong overall growth.
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