Cardiology Coding Alert

Hint: You may find overlap between 1995 and 1997 guidelines

You've asked questions about chronic conditions -- and we have answers.

Recognizing these three tricky areas of your chronic condition claims will help you secure payer reimbursement and avoid the headache of a bad audit.

Question 1: Does the Physician Have to Be There?

Chronic conditions may require frequent checkups that don't require the cardiologist to be there.

Example: A patient presents for a blood pressure (BP) check, taken by a registered nurse (RN) following the plan of care established by the physician for hypertension, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa.

Solution: For the BP check, again report 99211, Falbo says.

For the diagnosis, you'll need more details for the appropriate code. Depending on your documentation, 401.1 (Essential hypertension; benign) may be appropriate for the hypertension.

Important: There is no cheat sheet for coding chronic conditions -- you need to look for them on a case-by-case, visit-by-visit basis, says Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, a coding consultant and physician educator for the department of surgery at the University of Pittsburgh Medical Center. Example: High blood pressure may be a chronic condition for a patient who then makes some lifestyle changes that bring his blood pressure into the normal range.

Question 2: Are the 95,97 Guidelines Different?

Relief: No matter if you're following the 1995 or 1997 guidelines for E/M services , you'll find the same recommendations for handling the history of chronic or inactive conditions.

The 1997 documentation guidelines state that if your physician can update the status of three chronic or inactive conditions, the documentation meets the criteria for an extended history of present illness (HPI). This level of HPI is necessary for several commonly reported cardiology services including new patient office E/M 99203-99205, established patient office E/M 99214-99215, initial hospital care 99221-99223, initial observation 99218-99220, inpatient consultation 99253-99255, subsequent hospital care 99233, and office consultation 99243-99245.

Important: This chronic or inactive standard is a valuable alternative if the patient's presenting problem is not acute. Without signs and symptoms, your claim may have difficulty meeting the other standard for HPI, which requires the physician's documentation of at least four recognized HPI descriptors: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.

While the 1995 guidelines did not contain any verbiage specific to chronic/inactive conditions, Jim Collins, CPC-CARDIO, ACS-CA, CHCC, president of The Cardiology Coalition in Saratoga Springs, N.Y., obtained clarification directly from CMS that this provision applies equally to the 1995 set of guidelines.

According to Collins, a Medicare official confirmed, "The 95 guidelines were meant to be replaced by the 97 guidelines, but it never happened. The 97 guidelines were an expansion of the 95 guidelines, so it is acceptable to include the status of at least three chronic or inactive conditions also in the 95 guidelines." As such, you shouldn't find a difference between the "history" component of the 1995 and 1997 sets of documentation guidelines.

Question 3: What Should Be in the Documentation?

Proper documentation helps differentiate between management of stable chronic conditions and preventive medicine services. If the physician reports that the patient presented for a yearly visit, you're less likely to be coding a chronic condition than if the physician states the patient presented for a "follow-up," Hvizdash says.

Watch out: Many physicians would like to rely on the assessment/plan section of their visit note to support this history of present illness (HPI) documentation requirement. "There is nothing in the guidelines or CMS literature that would suggest this is not acceptable," Collins says. However, he adds that "it is somewhat risky to rely on assessment/plan documentation to support the most critical component of history. Some auditors may not give credit for history unless it is in the history section."

Example: The physician typically documents the history in the first part of the visit note following the patient's chief complaint or presenting problem. The history helps the physician determine which aspects of the physical exam to complete so he can continue the patient assessment and care plan. Documenting these factors also helps to support the level of medical decision-making for the encounter -- and avoid audit scrutiny.

Note: "Some payers have created audit tools that combine the guidelines in certain areas," Hvizdash says. "You'll want to check with your top payers to see what audit tool they use and make certain to stay current with them from time to time." Some carriers might not have an "audit tool" in place for you to follow. You should still talk with carriers and understand how they "judge" a provider's documentation during a payer's review.