Cardiology Coding Alert

Complete medical documentation for 99406 and 99407 should include the following information, as applicable, according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, staff services coordinator/billing/credentialing/auditing/coding at County of Stanislaus Health Services Agency in Modesto, Calif. and Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. in North Carolina:

• The amount of time spent on tobacco cessation counseling and the context in which the provider performed it.
• The patient's tobacco use - both timeframe and frequency.
• The patient's conditions adversely affected by tobacco use or the therapeutic agent affected by tobacco use.
• Medication management of smoking session drugs, when necessary.
• Notation of any methods or resources provided, including any handout or educational material the physician provided to the patient.
• The patient's willingness to quit smoking.
• Establishment of a "quit" date.
• Notes regarding follow-up.
• Prescriptions the patient is taking.