Cardiology Coding Alert

Experts offer 4 tips to make sure your systems add up Assigning the right exam level during an E/M visit depends on how well you understand the distinctions between problem-focused, expanded problem-focused, detailed, and comprehensive exam levels in the documentation guidelines - and that's just a start.
 
The key to getting exams right is tallying body areas and organ systems correctly, coding experts say. Exam Audit Turns Up Varied Responses Last month, we featured the results of our cardiology-specific analysis of the E/M documentation guidelines. Our 10 survey participants - all certified cardiology coders from across the country with an average of 12 years of coding experience - differed significantly in the way they coded the history portion of the sample visit note. (See "E/M Audit Results, Part 1: Are You Puzzled by the E/M Guidelines?" in the October 2003 Cardiology Coding Alert.)
 
Our exam component analysis reveals similar disparities in the levels of exam assigned to each of the five sample notes.
 
On average, the coders in our study agreed with the most frequently selected exam level only 55 percent of the time. Moreover, of the five encounter notes, there was not a single one in which they all agreed on the level of exam. 
 
This wide variance might not have been the case if the documentation guidelines were clearer, coding experts say. Look Over the Sample Exam Details Our volunteers' coding varied the most for a follow-up office visit for a patient with coronary artery disease (CAD) and diabetes. Only half of the coders agreed on the documented level of exam for this encounter. The report's actual exam details follow:

Weight: 187; Blood pressure: 140/68; Pulse: 64; Respirations: 18
Neck: No jugular venous distention (JVD). No carotid bruits.
Lungs: Clear
Cardiac: Regular rate and rhythm (RRR). No murmur/gallop.
Abdomen: He has a ventral rectus hernia. No mass/bruit.
Extremities: No clubbing/cyanosis (CC). Just a trace of pretibial edema. 

Review Our Coders' Answers So, how would you assign the exam level for this note? Here's what your peers said:
 
Of the eight coders who supplied their audit sheets, one assigned a "problem-focused" exam for this note, three assigned an "expanded problem-focused" exam, and four assigned a "detailed" exam. 
 
We took a close look at the audit sheets of the four coders who disagreed with the most common level of exam (detailed) and found that two participants applied the 1997 guidelines (which include specific exam elements) rather than the 1995 guidelines (which include broadly defined body areas), and awarded an expanded problem-focused level of service.
 
The remaining two coders used an audit sheet that differed from the others in distinctions between a problem-focused, an expanded problem-focused and a detailed level of exam
 
Overall, half of the [...]