Cardiology Coding Alert

You're having trouble deciphering the current E/M documentation guidelines, so you're looking for some direction, right? Our experts offer advice to help you find your way through the maze of components when selecting E/M codes. Look at Our E/M Analysis Since their introduction in the mid-1990s, the E/M documentation guidelines (both 1995 and 1997 versions) have baffled coders and physicians alike. "I find the E/M guidelines very difficult to understand and apply," says Kathy Zinger, CMM, RMC, office manager for Parkside Cardiology in Colorado Springs, Colo. Coders face this confusion frequently because about 70 percent of the CPT codes cardiologists report are E/M codes, coding experts say.
 
Moreover, federal auditors are looking closely at how cardiology practices apply these documentation guidelines. The E/M guidelines continue to "dominate the forefront of regulatory and compliance efforts for cardiology groups," says Jim Collins, CHCC, CPC, a cardiology coding consultant and president of Compliant MD Inc. To show you that you're not alone in facing your E/M coding challenges, Cardiology Coding Alert recently conducted a cardiology-specific analysis of the documentation guidelines. We gave the same packet of five cardiology encounter notes to 10 certified cardiology coders from across the country. On average, this group had 12 years of cardiology coding experience.
 
We expected to find many similarities in the way they applied the guidelines to the three key E/M components: history, exam, and medical decision-making (MDM). Even so, the participants only agreed with the most frequently selected E/M code 48 percent of the time and differed significantly in the codes they assigned, which may not have been the case if the guidelines were easier to follow. 
 
(Watch future editions of Cardiology Coding Alert for more on the E/M study results and tips for improving your examination and MDM coding.) Review the History Component Results Our volunteers' coding varied the most for an encounter note for a patient a cardiologist treated in the emergency department (ED) and then admitted to the hospital. The history component caused the widest variations. The report's history components follow:
 
Chief Complaint: Shortness of breath
 
History of Present Illness: This is a 34-year-old white male who presented to the emergency room today with increasing shortness of breath and orthopnea. No prior history of heart disease. No prior hospitalizations. He had chest tightness, associated left-arm discomfort. Chest x-ray showed pulmonary edema. Troponins are negative. He is a previous smoker. Admits to cocaine abuse. Says last two weeks ago. He is not now working. Admitted to me on cardiology service.
 
Past Medical History: No operations.
 
Review of Systems: Essentially unremarkable times 11, except the following. He is massively obese. He has chronic shortness of breath, dyspnea on exertion due to his size. Neurological: Negative. Psychiatric: [...]