Cardiology Coding Alert

Question: How can we support billing a level-four or -five E/M visit or add-on tests for asymptomatic patients with coronary artery disease (CAD)? There is no history of present illness (HPI), and the same amount of work is done on these patients as on those with symptoms. The only solution we can determine is to document the amount of time spent with the patient. Please let us know the appropriate coding and documentation guidelines for this example.

Texas Subscriber

Answer: According to the 1997 Evaluation and Management Code Guidelines, "the status of three (3) conditions" can be used in place of a detailed HPI. Should the physician spend more than 50 percent of face-to-face time with the patient performing counseling, then the doctor should document time, and you can choose the appropriate E/M code based on that time. Either situation would be appropriate to support billing of a level-four or -five E/M visit or add-on tests for an asymptomatic patient. If you use the 1997 Evaluation and Management Code Guidelines, make sure you follow those guidelines for all components of that visit.