Cardiology Coding Alert

Question: A 16-year-old patient is referred to a cardiologist for an initial evaluation of pectus excavatum. The cardiologist confirms the chest wall deformity, reviews its possible cardiac effects, orders an echocardiogram, and documents 48 minutes of total time on the date of the encounter. The patient has not received professional services from this cardiologist or another cardiologist of the same specialty and subspecialty in the same group within the past three years. Which diagnosis and evaluation and management (E/M) codes should we report?

California Subscriber

Answer: Report Q67.6 (Pectus excavatum) for the confirmed congenital chest wall deformity. The ICD-10-CM Tabular List identifies Q67.6 as a complete code that does not require a 7^th character, so do not look for an “initial encounter” extension.

For the office visit, report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded). The documented 48 minutes supports 99204 by time, assuming the record identifies the qualifying work performed and the payer follows CPT^® time rules.

Remember, “initial encounter” does not automatically mean “new patient.” New-patient status depends on whether the patient received professional services from the same physician or another physician or qualified healthcare professional of the same specialty or subspecialty in the same group during the preceding three years. If that requirement is not met, select the appropriate established-patient code instead.

Also report any separately documented symptoms or associated conditions when the provider evaluates and documents them — and they meet ICD-10-CM reporting criteria.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC