Cardiology Coding Alert

CPT code 99214 is an established patient visit code often reported by cardiology practices, and usually it is completely justifiable because of the nature and complexity of the problems patients with cardiovascular conditions present.

Some cardiologists, however, fearful of tossing up a red flag or uncertain about the documentation requirements, unnecessarily undercode these office visit. Others, meanwhile, bill the 99214 excessively with scant documentation, based on an ill-advised notion that virtually any visit to the cardiologist merits this relatively high-level evaluation and management (E/M) service.

For that reason, many carriers now are carefully scrutinizing 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: detailed history, detailed examination, medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patients and/or familys needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family) claims, says Terry Fletcher, BS, CPC, a coding and reimbursement specialist in Laguna Beach, Calif. Among office visit codes, the number one target for audit is 99214, Fletcher says, noting that some Medicare carriers now are asking for records on every third patient for whom a 99214 claim has been submitted. Cardiologists are being subjected to Medicare prepayment and postpayment reviews, she adds.

Documentation that consists of patient doing well; will return in six weeks doesnt come anywhere near satisfying the requirements for a level four visit, Fletcher says. Just because the patient is visiting a cardiologist doesnt mean the E/M code can be flat lined at level four.

The increased Medicare attention paid to 99214 claims, spurred by excessive coding, in turn has resulted in fewer 99214 claims by more cautious cardiologists, even when they have fulfilled the requirements for a level four visit, she says.

Other cardiologists, meanwhile, may have performed a level four service but dont document it correctly. Cardiologists need to be informed and educated, and periodic chart reviews should be performed to enable them to receive the full reimbursement that they are due, says Stacey Elliott, CPC, business office manager with COR Healthcare Medical Associates, an 11-physician cardiology practice in Torrance, Calif. Too often, the cardiologist performs a level of service but unfortunately documents a level much lower. And sometimes, the physicians lack of documentation prevents a bona fide service from being reimbursed at all.

Dont Underestimate Decision-making

Fortunately, satisfying the requirements for 99214 is not as difficult as many cardiologists believe, Elliott says. E/M services comprise of three components: history, examination and medical decision-making. For established patients, only two of these three components are requiredin most cases, history and decision-making (for established patients, the exam component is the least likely to be performed to the level of the total E/M service).

The crucial factor when determining the visit level that should be billed is medical decision-making, but only if supported by documentation of the patients history. Cardiologists, due to the nature of their work, often work with very ill patients. Although the level of decision-making often seems straightforward for the cardiologist, it may be considered more complex according to CPT and Medicare guidelines.

For office visits, there are four levels of medical decision-makingstraightforward, low complexity, moderate complexity and high complexityand each corresponds to a certain level E/M code. Level one and two E/M codes, for example, require straightforward medical decision-making, whereas level three codes require low complexity; level four codes, moderate; and level five codes, high complexity. But what the cardiologist considers straightforward, in fact, may be decision-making of low, moderate or even high complexity.

To calculate the correct level of medical decision-making, three categories must be considered:

Number of diagnoses or management options.
Tests and records reviewed or ordered.
Amount of risk to the patient.

Each category then is broken down. The number of diagnoses, other problems and management options either is minor (one problem); low (two problems); moderate (three problems, or one new problem with no workup); or high (four problems, or one new problem with workup). Similarly, the amount of data reviewed, ordered or to be ordered is minimal (zero to one test or record); limited (two tests); moderate (three); or extensive (four or more).

Note: The Health Care Financing Administration (HCFA) audit scorecards group together categories of clinical lab tests (e.g., CBC, urinalysis).

The third component involves evaluating the risk to the patient, which again is graded as minimal, low, moderate or high. Determining risk can be a subjective exercise, and cardiologists, like other medical specialists, tend to underestimate the risk in their own specialties because they are so familiar with the problems. To objectively gauge risk according to AMA/HCFA standards, Fletcher urges cardiologists to use Medicares Table of Risk (see Table 1 on page 28) because it conforms to the published standards.

The Table of Risk includes common clinical examples (e.g., prescription drug management or elective major surgery) and is divided into three sections (presenting problems, diagnostic procedures ordered and management options selected). The sections in the table should not be confused with decision-makings three components. The key thing to remember about the table is that the highest level in any one of its sections determines the entire level of risk. In other words, if the patient presents with only one problem and only minor diagnostic procedures are ordered (both minimal) but prescription drug management (moderate) is the management option, the overall risk level is moderate.

All these guidelines, categories and subcategories may seem intimidating and confusing, but if they are viewed simply as a systematized way of reporting what cardiologists regularly do when they see patients, they are much easier to understand.

Scenario: A male patient comes in to see the cardiologist for follow-up for coronary artery disease, hypertension, and hypercholesterol. The patient has been on long-term blood-thinning and cholesterol-lowering medication. The patient also reports episodes of shortness of breath and some chest tightness over the previous six weeks.

The cardiologist reviews the patients chart notes from his previous visit and discusses any respiratory or cardiovascular signs or symptoms that the patient has experienced since his last visit (including elements such as severity, duration, timing, etc.) and asks if the patient has been taking his medications regularly. The cardiologist also asks the patient if he has experienced any changes recently in activity, employment, diet, etc. A limited cardiovascular exam then is performed, and the cardiologist reviews the vitals taken by the medical assistant.

After reviewing the lab test results for prothrombin time and lipids, the cardiologist determines that the patient should increase the dosage of the cholesterol-lowering agent (i.e., Pravachol) and should keep taking Coumadin as prescribed. The importance of a low-fat diet and exercising regularly also is discussed. Finally, the cardiologist tells the patient to return in six weeks, and in the intervening time, more lab tests are scheduled.

In this scenario, the number of diagnoses or management options should be classified as extensive because the patient has new problems (i.e., shortness of breath, chest tightness) that require additional workup. According to the information provided, the only tests performed were labs, which qualify as minimal complexity of data (zero to one test or record). This category, however, is only one of three. In total, only two categories are needed to qualify for a specific level of decision-making. Risk, the third category, is quickly determined by checking the Table of Risk. In this scenario, the risk qualifies as moderate for two reasons: (1) the patient presents with a chronic illness with mild exacerbation; and (2) the cardiologist is changing the patients prescription drug regimen.

With two of three categories rated as moderate or high (number of diagnoses is extensive, and risk is moderate), the level of decision-making is moderate, which is the correct level of medical decision-making for 99214 (see Table 2 on page 29).

Note: Although the risk component of the decision-making qualifies as moderate in two categories, only one category of three of the Table of Risk needs to be met to qualify for a given level of risk.

How to Document Decision-making

For many cardiologists, the problem is not so much the decision-making requirements, but the fact that they must be documented. But this also is not as complicated as it appears. All the cardiologist requires is a record of what was ordered and reviewed, with all the patients problems written down. Viewed this way, the requirement shouldnt demand much additional effort on the cardiologists part because they gather all this information routinely anyway.

Neither HCFA nor private carriers dictate the form or style of the documentation; cardiologists can use standardized forms (see the example inserted) to note the elements that constituted their decision-making. They can customize a form of their own that conforms to their own way of practicing; or they can dictate, perhaps using a form as a guide to make sure they dont miss anything.

In the inserted form, the first section, Impression, would be used to note diagnoses and management options. The second and third sections note reviewed and ordered tests and other data. And the fourth section, entitled Plan, conforms to the Table of Risk.

If such a form has been completed correctly, all the documentation requirements for the decision-making component have been fulfilled.

Although determining the level of decision-making always has been a difficult task for coders who arent clinically trained, the recorded documentation gives the coder some tools to calculate the type of decisions the cardiologist had to make. Cardiologists also should consider determining their own E/M levels, in particular, the level of medical decision-making because they already have all the information about the patient and the treatment plan themselves.

Six Additional Tips on Medical Decision-making

1. All diagnoses listed should be accompanied by a descriptive term such as improved or worsening. If a definitive diagnosis cannot be reached, possible, probable or rule out diagnoses also should be listed.

2. Problems that are improving or resolved require less decision making than problems that are worsening or failing to change as expected.

3. The need to seek advice from others is an indication of complexity of decision-making. If the cardiologist decides to make a referral, request a consultation, or seek advice, clearly indicate in the record to whom and for what this decision is directed.

4. Statements such as WBC elevated or chest x-ray unremarkable could indicate that a test has been reviewed. Listing the data without mentioning whether it is normal or out of range is not recommended. Some commentary should accompany that type of information.

5. List the location and date of any separate lab or x-ray reports in the documentation, and initial and date the report to indicate when the information was reviewed.

6. Include a note to specify any findings from reviewing old records or additional information gathered from family members. If nothing else relevant was found, note that. Do not list old records reviewed or additional history obtained without elaborating on what was found.

Tip: Time is not a factor when it comes to determining the complexity of medical decision-making. A snap decision about how to treat a patient may take little time, but years of training and experience underlie the decision and, ultimately, that is what the cardiologist gets paid for.

Patient Questionnaire Fulfills History Requirement

The decision-making of moderate complexity required to bill a 99214 usually implies that a thorough history should be taken, and cardiologists normally do this. But because they (correctly) tend to be focused on the patients condition and dont want to waste time on other matters, the patients complete history doesnt always end up in the documentation. This may cause the patient no harm but certainly can hurt the cardiologists bottom line because without the appropriate level of history, a high-level E/M service cant be billed.

For example, if the documentation of the patient with CAD hypertension and cholesteremia discussed earlier required moderate decision-making (level four) but only a problem-focused history (level one), all the cardiologist can report is a 99211 because of the low level of history. The same visit with a comprehensive history (which probably was taken but not documented appropriately) could have been reported with 99214.

On the other hand, cardiologists dont want to spend an inordinate amount of time taking a patients history. One way they can get around this is to give each patient a history questionnaire that they can fill out for themselves. (If the patient is unable to complete the questionnaire alone, office staff can help, Fletcher says.) The questionnaire should include three sections:

chief complaint/history of present illness;
past/family/social history;
review of systems.

These classifications are the components that determine the level of history that was taken (see Table 3 below).

Section one of the questionnaire should let the patient describe:

location/site of the chief complaint;
quality of the problem (for example, sharp or dull pain);
severity of the problem (e.g., mild, moderate, extreme);
timing (during exercise, at night, etc.);
context (worsening, recurrent);
modifying factors (heat/cold, rest, limb elevation); and
associated signs or symptoms.

If one, two or three of the above elements are described by the patient, the history of present illness (HPI) is classified as brief; four or more elements constitute an extended HPI.

Section two should ask about:

past medical history (illnesses, operations, injuries, treatments, etc.);
family history (medical events, heredity); and
social history (marital status, occupation, habits, activities, sexual history).

If no medical, family or social history is indicated, the history will be limited to levels one and two.

Section three constitutes the review of systems (ROS) and should include a series of questions that help to identify any signs or symptoms that the patient may be experiencing to determine any underlying problems that may be related to the chief complaint. This also will help to identify any ongoing problems that might affect a choice of treatment for the current problem.

Medicare guidelines cite 14 elements in the review of systems, and 10 or more are required to document a complete review of symptoms. However, if you have documented the system(s) related to the problems, and there are no other significant findings in the other systems, a notation all other systems negative in the record fulfills this requirement and individual listings of all the systems is not necessary. If this statement is not present, then at least 10 systems must be documented separately to fulfill the requirement for a complete ROS (necessary for a comprehensive history, level four or five E/M). Alternatively, two to nine systems must be documented to describe an extended ROS (necessary for a detailed history 99214).

Once the information about the three elements has been gathered, the level of history can be calculated using Table 3 on page 30:

After the patient has completed the form, the cardiologist should review it with the patient and then sign it. On the form, or in a separate dictation, the cardiologist also should:

Note that the history was discussed with the patient.

Indicate what the significant findings were. For example, the dictation might state that patient has family history of heart disease. By discussing the findings, the cardiologist gets credit for everything on the questionnaire, regardless of its length, including review of systems and past, family and social history.

Specifically note the chief complaint, which is a requirement for any level of history. Without a chief complaint, an auditor has no way of knowing why the patient was treated. Although cardiologists, like other physicians, are taught to make intuitive jumps, these kinds of jumps may not be obvious to an auditor.

In the scenario described earlier, the cardiologist took a complete (two to three elements) past/family/social history because he asked about changes in activities, employment and diet; chief complaint/history of present illness would qualify as extended because the location, severity, timing and signs or symptoms of the problem(s) were noted; and review of systems would qualify as extended because problems with the cardiovascular and respiratory systems were indicated. Because two of the three components of the patients history meet the requirements for a detailed history (and the third, past/family/social history, is at a higher level yet), this history, documented properly, qualifies for 99214.

This visit would easily satisfy the requirements of a 99214 level visit if the physician documents the visit accurately, Elliot says, adding that the examination portion of the visit is not an issue here because only two of three E/M elements need to be met when coding an established patient visit.

Fletcher reminds cardiologists that time may be used as the sole factor in qualifying for a 99214 (or any other level of established or new patient visit) if counseling or coordination of care takes more than 50 percent of the entire encounter (25 minutes for a 99214). The time must be documented in the medical record, however, and must pertain to the reason for the patient visit.