Cardiology Coding Alert

Question: We recently finished our first internal audit and found a potential issue: One of the doctors told me that they only chose level 99212 when it is a follow-up from a previous visit. He chooses levels 99213 and above for everything else. I do not believe it is that simple because I thought even if it was not a follow-up visit, something like a minor problem might warrant 99212. Can you advise?

Washington Subscriber

Answer: You are correct. Not only can a follow-up problem-oriented visit for an established patient warrant a code other than 99212, but your coding should never hinge solely on whether a problem is new. The selection of an E/M level should be based on documentation and medical necessity.

If you have documentation that supports a comprehensive history and a comprehensive exam, but you are sending the patient home with a plan of rest and symptomatic treatment with mention of over-the-counter medications, that is a low level of medical decision-making, which typically would not warrant billing 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent face-to-face with the patient and/or family).

When physicians announce that they will only choose a particular level of service for a certain type of patient, that is typically a learned behavior which can hurt the physician in both ways (undercoding and overcoding). A “minor problem” could warrant a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family). But it could also warrant a higher level code depending on the patient’s other coexisting conditions, symptoms, and history. Each case should be coded individually based on the documentation.