Revenue Cycle Insider

Question: An established 68-year-old patient returns to the cardiology office for follow-up of atherosclerotic heart disease native coronary artery without angina pectoris and hyperlipidemia. The patient has no chest pain or dyspnea. The cardiologist reviews a recent lipid panel showing low-density lipoprotein (LDL) cholesterol of 92 mg/dL and triglycerides of 236 mg/dL. The assessment states “mixed hyperlipidemia, not at goal.” The cardiologist continues high-intensity atorvastatin, starts ezetimibe, counsels the patient about diet and medication adherence, and orders a repeat lipid panel in three months. The cardiologist documents 34 minutes of total time on the date of the encounter. Which codes should we report for the encounter and diagnosis?

Michigan Subscriber

Answer: For the encounter with an established patient, evaluation and management (E/M) service code 99214 (Office or other outpatient visit for the evaluation and management of an established 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, 30 minutes must be met or exceeded) is supported, as the documented 34 minutes meets the time requirement.

Although the service is supported based on time, the encounter may also support moderate medical decision making (MDM) because the cardiologist manages a chronic condition that is not at treatment goal and performs prescription drug management by initiating ezetimibe. When you use time for code selection, confirm that the documentation clearly supports the diagnoses addressed, medication-management decisions, follow-up plan, and total encounter time.

Report I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris) for the documented coronary artery disease. You may also report E78.2 (Mixed hyperlipidemia) because the cardiologist specifically documents mixed hyperlipidemia, assesses that the condition does not yet meet the treatment goal, and manages the condition by continuing statin therapy, initiating ezetimibe, providing counseling, and ordering follow-up lipid testing.

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