Cardiology Coding Alert

Acute cardiac conditions should have you considering high risk level.

You could be losing E/M credit unless your emergency, elective, and risk-factor vocabulary is rock solid. Under the Table of Risk's "Management Options Selected" column, these factors can change whether the level of risk is moderate or high, affecting the encounter's type of medical decision making and potentially changing the E/M service's level.

To avoid under- or over-coding the surgeon's level of risk, know the differences between:

emergency major surgery (high risk) and elective major surgery

elective major surgery with no identified risk factors (moderate risk) and those with identified risk factors (high risk).

Resource: If you want to review the Table of Risk, you can find one on page 14 of the 1995 E/M documentation guidelines or find one on page 50 of the 1997 E/M documentation guidelines, both of which are available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

Emergency Surgery Requires Immediate Performance When considering emergency surgery risk, look for the following characteristics described by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education with University of Washington Physicians.

Emergency surgery is surgery that must be performed immediately. Emergency surgery is at the highest risk category because the surgeon does not have time to do the typical clearance work. Procedures that qualify as emergency surgery include things like ruptured aneurysm, some acute cardiac conditions, and other surgeries that cannot be delayed for further work-up.

Risk Factors Apply to Individual

All surgeries carry some inherent risk. The "Management Options Selected" column's designation of with and without identified risk factors refers to patient-specific risks. Look for any comorbidity the patient has that affects the visit.

Elective surgery with no identified risk factors is any surgery that is not immediately required (meaning, it is planned for the patient's convenience) or is "cosmetic when the patient has no comorbid conditions that will increase the risk associated with the procedure, healing, and/or anesthesia," Bucknam explains.

Translation: Elective surgery involves a generally healthy person who needs surgery to correct a problem, and the physician expects the person will be healthy again after the surgery. "Elective surgery with identified risk factors is any surgery that is not immediately required when the patient DOES have comorbid conditions that will increase the risk associated with the procedure, healing and/or anesthesia," Bucknam says.

She notes that common risk factors include the following: 

Diabetes: affects healing; also patient must be NPO (Nothing by mouth) before surgery and often cannot eat for a while after surgery, so blood glucose must be closely monitored COPD: increased anesthetic risk Tachycardia with or without pacemaker: many common surgical tools (for example, electrocautery) can trigger a tachycardic event, and if the patient has a pacemaker, it must be turned off during surgery.

"There are many other risk factors, including drug allergies, previous poor anesthetic outcome, morbid obesity," just to name a few, Bucknam adds.