Cardiology Coding Alert

Question:  How should I code the following case for an established patient?

• More than 10 minutes discussing importance of quitting smoking
• Comprehensive history, comprehensive exam, moderate MDM
• ECG and interpretation
• Occasional palpitations, benign HTN, tobacco use, atypical chest pain, COPD.

Florida Subscriber

Answer: Your case involves tobacco cessation counseling, an established patient office visit, and electrocardiogram (ECG) for a patient with multiple diagnoses. Assuming there's proper documentation, you may report the ECG and tobacco cessation counseling in addition to the E/M service.

Smoking cessation: The physician documents more than 10 minutes of counseling, so you should report 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). Be sure the session meets payer frequency requirements. Also, remember Medicare has distinct codes if the patient is asymptomatic for tobacco-related disease (G0436-G0437, Smoking and tobacco cessation counseling visit for the asymptomatic patient ...). This patient has COPD so the G codes would not apply.

E/M: For this established patient visit, you need to meet two of the three component levels for history, exam, and medical decision making (MDM). The noted levels seem to support 99215 (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 comprehensive history; A comprehensive examination; Medical decision making of high complexity ...).

However, the E/M service must be distinct from the smoking cessation to be billable. In other words, you must remove all services related to the tobacco cessation (subjective, objective, assessment, and plan of care) when considering your E/M service level. As a result, documentation actually may support a lower code, such as 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 ...).

Because you're also reporting smoking tobacco cessation counseling, you should append modifier 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service) to the E/M code.

ECG: You indicate both performance and interpretation of the ECG, so you should report 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report).

Diagnoses: For the diagnoses, you should report the following:

• 785.1, Palpitations
• 401.1, Benign essential hypertension
• 305.1, Nondependent tobacco use disorder
• 786.50, Unspecified chest pain
• 496, Chronic airway obstruction, NEC.