E&M Codes: Trends in the RVU bonus of a clinical inpatient IR service

Learning Objectives: -  Describe the difference between Evaluation & Management (E&M), Current Procedural Terminology (CPT), and procedural CPT codes
-  Describe the trends in Vascular & Interventional Radiology (VIR), RVUs (Relative Value Units) for a few select inpatient E&M and procedural codes
-  Forecast how billing for clinical E&M services can make up for RVU cuts in procedural services
-  Demonstrate that a clinical approach to VIR in the inpatient setting can augment the economic value of a hospital-based IR practice

Background:

The RVU system is crucial for determining reimbursement rates for medical procedures and services under the Medicare Physician Fee Schedule (PFS). While hospitals are reimbursed in a bundled manner based on diagnostic-related groups (DRGs), administrators continue to use RVUs internally to quantify productivity. Over the past twenty years, there has been a decrease in RVU values for many vascular & interventional radiology (VIR) procedures and an increase in RVU values for Evaluation & Management (E&M) codes. This trend has coincided with increasing clinical emphasis in VIR. Thus, billing E&M codes for clinical work may allow VIRs to compensate for these cuts and demonstrate the value of a clinically oriented hospital-based IR practice.

Clinical Findings/Procedure Details: We present trends in procedural codes for Transjugular Intrahepatic Portosystemic Shunt placement (37182), drain placement (49405), and embolization (37243) as well as E&M codes for initial and follow up inpatient encounters from 2003-2024 based on the PFS Relative Value Files. These codes are representative of a variety of inpatient VIR services performed at our hospital. We construct a “clinical bonus” metric of one initial level 2 encounter (99222) and two follow up level 2 encounters (99232) and trend this as well. Overall, the clinical bonus has increased over time and serves to buffer the effects of procedural RVU cuts.

Conclusion and/or Teaching Points:

This analysis of RVU compensation from 2003 to 2024 highlights differences between VIR procedural and E&M codes. The increasing RVU compensation for E&M services suggests that billing for these services, which are commonly already being performed, can help mitigate the impact of RVU reductions and highlight to stakeholders the comprehensive value of a clinical VIR approach in the inpatient setting.