Cardiology Coding Alert

If you're having trouble pinning down the right level of medical decision-making (MDM), you're not alone. Take a look at the results of our sample study to see how your colleagues are handling this tricky part of the E/M encounter.

Complexity Gives Coders Fewer Headaches

In the past two issues, we've featured the results of our cardiology-specific analysis of the E/M documentation guidelines and offered best-practices advice for improving your E/M coding for the history and exam components.
 
Although our 10 survey participants (all certified cardiology coders with an average of 12 years experience) agreed more often on how to calculate the medical complexity portions of the sample notes than on the history and exam components, they still varied widely in their complexity component responses.
 
(To read the official documentation guidelines, go to http://cms.hhs.gov/medlearn/emdoc.asp.)

Review the Sample Note's Complexity Details 

Our volunteers' responses varied the most for a new patient encounter with a female referred to the cardiologist by her ob-gyn doctor for a heart murmur. The report's actual complexity-pertinent details follow:

EKG: Performed in our office interpreted by me is a sinus rhythm. She has some nonspecific inferior T-wave changes, otherwise no evidence of left ventricular hypertrophy (LVH). Normal limits: PR, QRS and QT intervals. 
 
IMP: Fatigue, dyspnea on exertion (DOE). May be related to job stress, excessive hrs, possibility of hypothyroidism is a consideration, and her obesity is adding to this as well with decreased exercise tolerance. Other consideration could be left ventricle (LV) systolic or diastolic dysfunction. I cannot detect an obvious murmur, certainly not a pathological murmur at this time. 

PLANS:
 1. I would start off with thyroid function tests (TFTs), which can be obtained through her ob-gyn physician. If not, we will be happy to obtain them through our lab. Will obtain an echo to assess her LV function as well as to assess right ventricle (RV) pressures and rule out (R/O) possibility of pulmonary hypertension. 
 2. If all of this workup is negative, I would consider a sleep study in this patient w/excessive daytime sleepiness and snoring at night as well.

Assess Our Coders' Answers

So, what steps would you take to assign the appropriate medical complexity level for this encounter? Here's what your peers said:
 
Of the eight participants who supplied their audit sheets, two coders assigned a low level of complexity, three assigned a moderate level, and the remaining three assigned a high level of complexity. Our expert reviewers agree that the note supports the highest level of complexity, or code 99205, if the history and exam requirements are met. (See "4 Strategies Help You Sharpen Your MDM Tool Skills"  for specifics on how they chose this code.)