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 [...]