Wiki Cardiac diagnoses on table of risk

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jdibble

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I am new to cardiology coding and was hoping someone might be able to help me with what cardiology diagnoses would be considered high risk on the table of risk or how you would detemine this? My doctors believe that everything they treat is high risk, whether it is in the office, hospital, stable, etc., they believe it should be considered high risk because of their expertise.

I know this is a broad question, but I was hoping that someone could give me some pointers on what is what with cardiac diagnoses.

Thanks,
 
Jodi,
The rule of thumb is that you code what the physician states is the patient's diagnosis. Whether it be "high risk" or not, those are guidelines. Are you asking generally how to place your codes as HCC (Hierarcy Coding)?

I would love to help you but, I need some additional information :)
 
Thanks Amy for trying to help! What I am trying to determine is the risk, or severity of a cardiac disease. For example, I know that a MI is high risk, but if the patient has a diagnosis of a-fib or CHF, with nothing else documented except possibly acute or chronic would this be considered high risk on the table of risk? I am trying to figure out when any cardiac diagnosis would be considered high risk. My providers are telling me that every patient they see is of high risk and they should be entitled to bill with a higher level based the medical necessity because of their expertise! This applies to patients that are just coming in for their 6 month or annual f/u exams for stable cardiovascular diagnoses - so would these be high risk diagnoses just because they are cardiac conditions?

I'm not sure if I am making sense, but this is the best I can explain it! :eek:

Thanks,
 
So basically they are trying to obtain a higher level of Evaluation and Management due to the "high risk" of the patient's diagnosis. I see now. You can only code for the level of E/M that the physician provides no matter how "high risk" the patient is. If the physician only sees the patient for 15 minutes and does not complete a level 4 H/P, or ROS then they will only receive a level 3 E/M for that visit.

If this was true, every physician would say that they are "high risk" providers and try to get around the levels of E/M by stating as such.

Hope this helps!
 
Thanks Amy...I understand what you are saying. The reason I am asking this is because they are documenting a comprehensive history and exam. For the MDM, they paid for someone to "teach" them documentation short cuts and now they are using key phrases such as "I personally reviewed the EKG..." or "I reviewed old records" etc. in order to gain higher points in the data section. The issue is that most of the time the deciding factor for a higher level is whether the risk is moderate or high! And since they think every patient they see is high risk because they are specialists, I have issues when I have to down code their 99205 and 99223 visits for patients with dx's such as chest pain or stable CHF, etc. So I was trying to get an idea of what is a high risk cardio dx vs. one that would be moderate!

Thanks for your help!
 
If all they are documenting is a fib with congestive heart failure nothing else stated then they are considered stable chronic illness which is a moderate. If they state severe exacerbation, it's then considered high risk.

Here is medicare's guidelines for e/m risk factors.

Moderate

• One or more chronic illnesses with
mild exacerbation, progression, or
side effects of treatment
• Two or more stable chronic
illnesses
• Undiagnosed new problem with
uncertain prognosis (lump
in breast)
• Acute illness with systemic
symptoms (pyelonephritis,
pneumonitis, colitis)
• Acute complicated injury
(head injury with brief loss
of consciousness)
• Physiologic tests under stress
(cardiac stress test, fetal
contraction stress test)
• Diagnostic endoscopies with no
identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies
with contrast and no identified risk
factors (arteriogram, cardiac
catheterization)
• Obtain fluid from body cavity
(lumbar puncture,
thoracentesis, culdocentesis)
• Minor surgery with
identified risk factors
• Elective major surgery
(open, percutaneous
or endoscopic) with no
identified risk factors
• Prescription drug
management
• Therapeutic nuclear
medicine
• IV fluids with additives
• Closed treatment of
fracture or dislocation
without manipulation

High

• One or more chronic illnesses with
severe exacerbation, progression,
or side effects of treatment
• Acute or chronic illnesses or
injuries that pose a threat to life
or bodily function (multiple
trauma, acute MI, pulmonary
embolus, severe respiratory
distress, progressive severe
rheumatoid arthritis, psychiatric
illness with potential threat to self
or others, peritonitis, acute
renal failure)
• An abrupt change in neurologic
status (seizure, TIA,
weakness, sensory loss)
• Cardiovascular imaging studies
with contrast with identified risk
factors
• Cardiac electrophysiological tests
• Diagnostic Endoscopies with
identified risk factors
• Discography
• Elective major surgery
(open, percutaneous or
endoscopic) with identified
risk factors
• Emergency major surgery
(open, percutaneous or
endoscopic)
• Parenteral controlled
substances
• Drug therapy requiring
intensive monitoring for
toxicity
• Decision not to resuscitate
or to de-escalate care
because of poor prognosis

http://www.cms.gov/Outreach-and-Edu.../Downloads/eval_mgmt_serv_guide-ICN006764.pdf
 
If all they are documenting is a fib with congestive heart failure nothing else stated then they are considered stable chronic illness which is a moderate. If they state severe exacerbation, it's then considered high risk.
Click to expand...

Thanks Amanda - that was helpful information! I think that is what part of the issue is - they never document if there is severe exacerbation or if it is stable. They only document acute or chronic.
 
jdibble said:
Thanks Amanda - that was helpful information! I think that is what part of the issue is - they never document if there is severe exacerbation or if it is stable. They only document acute or chronic.
Click to expand...

Just because the docs are specialist does not make every problem a high risk for determining the level of e&m code. I have had docs tell me the same thing that every patient is high risk. They are speaking in clinical terms. But for that days visit are they high risk? That is the question you need to ask them? Are they are risk right now during the visit? Are they having a MI or respiratory failure in the office? You see the difference?

It all comes down to medical necessity not just medical decsion making. For MDM you can see the difference between Moderate and High. The High would have to be documented as severe life threatening right now. If this is the case and the patient is in the office for a visit they better call the ambulance and get them to the hospital! The moderate category is mild exacerbation or two or more stable chronic illnesses. They will be going home and come back later for a check up. Now there is nothing wrong with the doc wording his documentation correctly to gain points for his data section if he actually thought it was medically necessary to go over the old records etc.

You should to let them know they can use the descriptive words Severe. Mild, progressive,stable if that is the actual case. That way there is no confusion about how sick the patient was or is. An auditor or coder has to be able to read the dictation and be able to tell from dictation what is going on. Not just doc to doc(these days) otherwise they will not get the money they are owed. ALways point out the money part.
 
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Any provider can document a comprehensive exam and history, and even treatment plan, however the question is SHOULD that have been necessary give the patient diagnosis. This is why CMS has stated that medical necessity is the overarching criteria for a visit level. Remember severity of illness must match intensity of the service provided. So while all the points of an exam might be documented, we count only those points that relate to the reason for the encounter. If the provider uses a template, then only those points that have some type of customized statement for that patient at that encounter can count. Just making a check mark or pulling from a previous visit are not points can be counted. Just doing it does not count. Did it need to be done, that is what counts.
 
mitchellde said:
any provider can document a comprehensive exam and history, and even treatment plan, however the question is should that have been necessary give the patient diagnosis. This is why cms has stated that medical necessity is the overarching criteria for a visit level. Remember severity of illness must match intensity of the service provided. So while all the points of an exam might be documented, we count only those points that relate to the reason for the encounter. If the provider uses a template, then only those points that have some type of customized statement for that patient at that encounter can count. Just making a check mark or pulling from a previous visit are not points can be counted. Just doing it does not count. Did it need to be done, that is what counts.
Click to expand...

true that!!
 
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