Wiki Cardiology E/M office visit

[Georgie]

I am new in Cardiology coding (about 4 months now) and am trying to be better in selecting level of care and documenting the dx codes.
This is just an example:

In the A&P:
1. Hospital discharge follow-up: Z09
2. STEMI: I21.02
3. Essential HTN: I10
4. Type 2 DM: E11.59
5. Morbid Obesity: E66.01
6. Hyperlipidemia: E78.2

Refilled ticagrelor, 90mg

Plan detail: Continue present management. Return to clinic in 3 months.

The HPI would be detailed w/the hx of the codes #3-6 and more in depth about the STEMI which happened at least 2 months prior to DOS.
-------------------------------
My questions:
1. I was told that Z09 is not to be used as primary. Do I change to Z51.89?
2. Since the STEMI happened at least 4 weeks prior to DOS, would I change the STEMI to I25.2 and code Z09 2nd? Or use Z51.89 in place of Z09?
3. How would you code this in order? I assume I would add the rest of the codes.

The following is what I'm thinking to use:
Z51.89
I25.2
I10
E11.59
E66.01
E78.2

4. Would this be 99213, 99214, 99215? There are no minutes noted in documentation.

Thank you in advance for any input you can provide.

 

[Papitha]

Level is 99214 as the Problem warrants for Moderate complexity "2 or more stable chronic illnesses" (HTN, DM & HLD), Risk warrants for moderate complexity "Prescription drug management" (Refilled ticagrelor, 90mg). Regarding the PDX if you can elaborate the reason for this visit, I can suggest the appropriate ICD. I do not think so that the ICD Z51.89 is the appropriate PDX.

 

[Georgie]

Level is 99214 as the Problem warrants for Moderate complexity "2 or more stable chronic illnesses" (HTN, DM & HLD), Risk warrants for moderate complexity "Prescription drug management" (Refilled ticagrelor, 90mg). Regarding the PDX if you can elaborate the reason for this visit, I can suggest the appropriate ICD. I do not think so that the ICD Z51.89 is the appropriate PDX.

Thank you so much, Papitha!

The majority of these office visits are hosp follow-ups or 3,6, or 1-yr checkups. The doctors would list all these dx & s/s that sometimes they are not even mentioned in the narratives, which is why I struggle with the dx codes and level of care. One time I had torn meniscus tear along with 10 other dx/s/s and I'm thinking, "what does the torn meniscus have to do with cardiology?" Of course, there would be HTN,CAD/DM, etc.., all the good stuff. Just a checkup.