Cardiology Coding Alert

E/M Audit Results:

Part 1: Are You Puzzled by the E/M Guidelines?

You're having trouble deciphering the current E/M documentation guidelines, so you're looking for some direction, right? Our experts offer advice to help you find your way through the maze of components when selecting E/M codes.

Look at Our E/M Analysis

Since their introduction in the mid-1990s, the E/M documentation guidelines (both 1995 and 1997 versions) have baffled coders and physicians alike. "I find the E/M guidelines very difficult to understand and apply," says Kathy Zinger, CMM, RMC, office manager for Parkside Cardiology in Colorado Springs, Colo. Coders face this confusion frequently because about 70 percent of the CPT codes cardiologists report are E/M codes, coding experts say.
Moreover, federal auditors are looking closely at how cardiology practices apply these documentation guidelines. The E/M guidelines continue to "dominate the forefront of regulatory and compliance efforts for cardiology groups," says Jim Collins, CHCC, CPC, a cardiology coding consultant and president of Compliant MD Inc. To show you that you're not alone in facing your E/M coding challenges, Cardiology Coding Alert recently conducted a cardiology-specific analysis of the documentation guidelines. We gave the same packet of five cardiology encounter notes to 10 certified cardiology coders from across the country. On average, this group had 12 years of cardiology coding experience.
We expected to find many similarities in the way they applied the guidelines to the three key E/M components: history, exam, and medical decision-making (MDM). Even so, the participants only agreed with the most frequently selected E/M code 48 percent of the time and differed significantly in the codes they assigned, which may not have been the case if the guidelines were easier to follow. 
(Watch future editions of Cardiology Coding Alert for more on the E/M study results and tips for improving your examination and MDM coding.)

Review the History Component Results

Our volunteers' coding varied the most for an encounter note for a patient a cardiologist treated in the emergency department (ED) and then admitted to the hospital. The history component caused the widest variations. The report's history components follow:
Chief Complaint: Shortness of breath
History of Present Illness: This is a 34-year-old white male who presented to the emergency room today with increasing shortness of breath and orthopnea. No prior history of heart disease. No prior hospitalizations. He had chest tightness, associated left-arm discomfort. Chest x-ray showed pulmonary edema. Troponins are negative. He is a previous smoker. Admits to cocaine abuse. Says last two weeks ago. He is not now working. Admitted to me on cardiology service.
Past Medical History: No operations.
Review of Systems: Essentially unremarkable times 11, except the following. He is massively obese. He has chronic shortness of breath, dyspnea on exertion due to his size. Neurological: Negative. Psychiatric: Drug addiction. Genitourinary: History of urinary tract infection. E coli. Hematologic: Negative. Gastrointestinal: No GI bleeds. The remainder of the review of systems is negative.
Social History: He is single. Lives with his dad. He is not working.

In addition, the note concluded with "Plan: ICU, IV lasix ...," which, with the encounter title "History and Physical Exam," appears to confirm that this was an inpatient admission (99221-99223), Collins says. Only 50 percent of the coders, however, assigned an admission code: Three reported 99221, one coder assigned 99222, and another reported 99223. The rest of the coders applied the following codes to the note: One reported 99232 for subsequent hospital care of moderate complexity; one assigned 99233 for high-complexity subsequent hospital care; one reported 99253 for a low-complexity initial inpatient consultation; another assigned 99283 for an expanded, problem-focused ED visit; and one reported 99499 for an unlisted E/M service.

Use the Grid as a Guide

So, how would you assign the level of history for this note? Most of our volunteers recorded their results on audit sheets similar to this one:
Note: You can meet the 1997 HPI requirements for detailed and comprehensive levels of history if the report indicates the status of three chronic/inactive conditions. 
Our participants agreed on several points:

  • All the participants counted "shortness of breath" as the chief complaint.
  • All used "associated left arm discomfort" for the associated signs and symptoms under the HPI section.
  • Nobody gave credit for the timing component of HPI.
  • Everybody gave credit for a complete review of systems, using the phrase "essentially unremarkable times 11" or "The remainder of the review of systems negative." Under the guidelines, a complete ROS requires that the physician document review of "at least 10 organ systems" and individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating that all other systems are negative is permissible, according to the guidelines.
  • All the participants credited past history using the statements "no prior history of heart disease" and/or  "no operations."
  • All the volunteers credited social history (smoker and cocaine abuse).

    But our participants disagreed on more points:

  • Five participants checked location under HPI for the statement "He had chest tightness" or assumed that shortness of breath is located in the lungs.
  • Five coders checked quality for chest sensation as "tightness."
  • Two participants checked severity for the comment "increasing shortness of breath." 
  • Two coders checked duration for the statement that the patient used cocaine as recently as "two weeks ago."
  • Only one participant gave credit for context.

    Although the guidelines don't specify what "context" actually refers to, many consider this a description of the onset of symptoms, such as "While mowing the grass, the patient had chest pain," Collins says. The comment in this note that might present the context of this patient's condition is "presented to the emergency room ... with increasing shortness of breath," he adds.

  • Three of our participants gave credit for modifying factors. To find a modifying factor, you should look under the ROS at the statement "dyspnea on exertion," Collins says. In fact, you can use elements from the ROS or any other portion of the note to generate credit for HPI elements as long as the same element is not counted twice, he says. Specifically, by awarding credit for this statement under the HPI section, we could not also credit it under the ROS section. Since the physician said that all other systems were negative, however, this is not a limiting factor, he says.

  • Only one participant gave credit for family history, using the statement, "He lives with his dad." The documentation guidelines define family history as "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk." But most of the participants did see the patient's living arrangements as crucial, Collins says.
    In general, the participants' consensus is that the report supports a "detailed" level of service and a low-level admission code, such as 99221. Moreover, nine out of 10 coders did not mark "family history," which prevents a "comprehensive" history designation supporting a higher-level admission code.
    Overall, these results indicate that the "history component is by far the toughest, most documentation- intensive portion of the guidelines," Collins says.
    But you can simplify the history component process by improving your patient history questionnaires, Collins adds. Nonphysician staff and patients can document most of the history components (ROS and/or PFSH) as long as the physician makes a notation supplementing or confirming the information recorded by others, according to the guidelines.
    "A well-designed questionnaire and a little bit of training make a molehill out of this documentation mountain," Collins says.
    Note: To read the 1995 and 1997 documentation guidelines, see