Few Do Most: National Patterns of Cognitive-to-Procedural Share among United States IR Physicians

To quantify evaluation and management (E&M) billing patterns among U.S. interventional radiologists.

A cross-sectional analysis was performed using a 100% sample of 2023 Medicare fee-for-service claims. Interventional radiologists were stratified into 3 mutually exclusive interventional radiologist (IR)-related workload tiers by work relative value unit (wRVU; 10%-49%, 50%-89%, and ≥90%). Multivariable negative-binomial regression was adjusted for total wRVUs and physician/practice characteristics.

Among 5,232 interventional radiologists, E&M billing increased disproportionately with IR-related workload. Across increasing IR-related workload, surgical procedure relative value units increased by 4.2-fold, whereas E&M relative value units increased by 23.9-fold. Only 23.5% of interventional radiologists billed ≥11 E&M claims. After adjustment for total wRVUs, interventional radiologists in the 10%-49% and 50%-89% workload tiers billed 90% fewer E&M encounters (adjusted relative rate ratio [aRRR], 0.10; 95% confidence interval [CI], 0.10-0.11) and 28% fewer (aRRR, 0.72; 95% CI, 0.66-0.79), respectively, than interventional radiologists in the ≥90% tier. Among interventional radiologists billing ≥11 E&M claims, tier-based differences attenuated, with the 50%-89% tier approaching parity with the ≥90% tier (aRRR, 0.89; 95% CI, 0.78-1.003). Female sex was associated with fewer E&M claims overall (aRRR, 0.82; 95% CI, 0.75-0.89), but more in the ≥11-claim subset (aRRR, 1.25; 95% CI, 1.03-1.52).

E&M billing among U.S. interventional radiologists is concentrated among a minority of physicians and increases disproportionately with IR-related workload. Attenuation of workload-tier differences among interventional radiologists billing ≥11 E&M claims suggests observable E&M engagement reflects a distinct clinical practice model rather than a simple function of procedural volume. Structural factors, including sex, may influence participation in observable E&M billing.