Cardiology Coding Alert

Question: The cardiologist performed a comprehensive exam and high complexity medical decision making for a new patient who presented with fever and chest pain. He suffered a myocardial infarction (MI) several weeks ago. The cardiologist documented a diagnosis of Dressler's syndrome. If the cardiologist addressed five history of present illness (HPI) elements and reviewed 10 systems (ROS), what is the history level?

California Subscriber

Answer: CPT bases the history level on HPI, ROS,and personal past, family, and social history (PFSH), so you'll have to review the notes to determine the PFSH level before deciding on a history level. During a "complete" PFSH for a new patient, the physician asks the patient direct questions about all three PFSH elements. If she only asks a new patient about one or two PFSH elements, it is a "pertinent PFSH." You may need to hunt for the PFSH within the body of the HPI or ROS because the information may not be marked separately.

HPI, ROS levels: The 1995 and 1997 E/M documentation guidelines both indicate that four HPI elements (and therefore the five in your example) qualify as extended HPI and 10 systems equal a complete ROS (guidelines available for download at www.cms.gov/MLNEdwebGuide/25_EMDOC.asp).

Once you've determined the HPI, ROS, and PFSH levels, you can determine the history level. You must meet all three requirements for a given history level. Following are the requirements for a comprehensive history:

If you meet the following requirements, you instead have a detailed history:

Result: Based on your case, if your documentation shows extended HPI, complete ROS, and complete PFSH, this qualifies as a comprehensive history. If instead the case you describe supports extended HPI, complete ROS, and pertinent PFSH, this is a detailed history (because you must meet all three requirements of a given level).

ICD-9: ICD-9 indexes Dressler's syndrome to 411.0 (Postmyocardial infarction syndrome). Interestingly, ICD-10-CM 2010 also uses the same code for Dressler's and postmyocardial infarction syndrome, but the definition puts Dressler's in the spotlight: I24.1 (Dressler's syndrome). You can find out more about ICD-10-CM, expected to replace ICD-9-CM in the U.S. in 2013, at www.cdc.gov/nchs/icd/icd10cm.htm.

-- You Be the Coder and Reader Questions prepared with the assistance of Jim Collins, CCC, CPC, CHCC, president of CardiologyCoder.Com.