Cardiology Coding Alert

Never assume certain cardio diagnoses merit high-level E/Ms

Your cardiology practice is more likely to report CPT 99213 and 99214 than other established patient E/M codes, but watch out. Payers audit 99214 more than any other E/M code.

Follow our tips to determine when you can bump your visit up to 99214 and when you should stay in the 99213 zone.

Tip 1: Nail Down Vital 99213-99214 Elements

Pay attention to the differences in the descriptors for 99213 and 99214 (emphasis added):

• 99213--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

• 99214--a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

You can successfully code and document level-four established patient office visits (99214) for many of your cardiology patients by remembering the code's minimum criteria. Compare 99213's E/M documentation guidelines to 99214's.

Tip 2: Avoid Common Upcoding Mistakes

If your cardiologist's documentation supports a level-four visit, you should report 99214. But watch out for these hidden traps:

1. Make sure your doctors understand that medical necessity is the overreaching criterion that dictates the level of service they provide. Automated systems set up to document every possible piece of history and examination for every patient will certainly attract the attention of auditors. 

Payers and auditors may view obtaining a higher-level component than medically necessary just to charge a higher-level E/M service as "gaming the system," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

2. You should keep in mind that E/M codes aren't completely diagnosis-driven. Don't assume you can report higher-level E/M codes for cardiology patients-- base your E/M choice on the documentation.

Example: A patient follows up with your doctor for his diagnosed coronary artery disease (414.01). You know this case has required moderate-complexity medical decision-making (MDM) in the past, but at this appointment the cardiologist documents an expanded problem-focused history and an expanded problem-focused exam, and the visit note supports medical decision-making of only low-complexity:

• limited diagnoses or management options

• limited amount and/or complexity of data to be reviewed

• moderate risk of complications and/or morbidity or mortality.

This service merits 99213, not 99214.

Tip 3: 99213 for Every Visit May Send Red Flags

Some insurers put up red flags when a practice only reports 99213 for established patient E/M services, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that, she adds.

Solution: Choose your E/M code based on the cardiologist's documentation every time, and your coding will naturally reflect the cardiologist's range of services. Here's what you should look for with each code:

Test Yourself With This Scenario

Scenario: A male patient comes in to see the cardiologist for follow-up for coronary artery disease, hypertension and hypercholesterol. The patient has been on long-term blood-thinning and cholesterol-lowering medication. The patient also reports episodes of shortness of breath and some chest tightness over the previous six weeks.

The cardiologist reviews the patient's chart notes from his previous visit and discusses any respiratory or cardiovascular signs or symptoms that the patient has had since his last visit (including elements such as severity, duration, timing, etc.) and asks if the patient has been taking his medications regularly. The cardiologist also asks the patient if he has had any changes recently in activity, employment, diet and so on. The cardiologist then performs a limited cardiovascular exam and reviews the vitals taken by the medical assistant.

After reviewing the lab test results for prothrombin time and lipids, the cardiologist determines that the patient should increase the dosage of the cholesterol-lowering agent (such as Pravachol) and should keep taking Coumadin as prescribed. The cardiologist also discusses the importance of a low-fat diet and regular exercise. Finally, the cardiologist tells the patient to return in six weeks, and in the intervening time, schedule more lab tests.

Solution: You should report this visit with 99214. Here's why:

History
Chief Complaint: Follow-up
HPI: location, severity, duration, timing, etc. (at least four elements documented)
ROS: shortness of breath and chest tightness brings you to the level needed for a level-four service
Past Medical History: the patient has been on a blood- thinning agent, etc.

Exam
Vital signs (constitutional) and cardiovascular = two elements of exam (expanded problem focused).

Complexity of MDM
The patient has three conditions: coronary artery disease, hypertension and hypercholesterol. At least one of these is not stable because the patient is having chest pain and shortness of breath. This will bring the first element of complexity up to the highest level.

The amount of risk associated with the visit is moderate, based on the table of risk (established problem with exacerbation and medication management).

Note: Medical data reviewed is not a factor because the doctor only looked at lab tests. On the other hand, the other two factors (discussed above) support the moderate level of complexity needed to report 99214.

Conclusion: The history and complexity of MDM support a level-four service, while the exam indicates only a level-three service. Because only two of the three elements of documentation must meet/exceed the requirements, this note supports a level-four service.