Coding the Cardiology Consult

Vol. 17 •Issue 2 • Page 5
Coding Corner

Coding the Cardiology Consult

Note that the American Medical Association revised code 99253, Inpatient consultation for a new or established patient, for 2007.

Presentation: The patient is a 71-year-old gentleman who is admitted to the hospital with chest pain. I have been asked to see him by Dr. Jones to evaluate his cardiac function.

History of Present Illness: This patient denies any history of cardiac problems. He recently completed a 14-hour drive from North Carolina, and he had no particular problem with that journey.

The following day, the patient was going about his usual activities and felt well, when he began experiencing a sudden onset of retrosternal pressure discomfort. This was nonradiating, but the patient did break out with a profuse diaphoresis. There was no nausea or emesis. The discomfort itself was described by the patient as being moderately severe.

The patient was brought to the emergency room and has been admitted for observation. The patient’s EKG tracing showed sinus rhythm with nonspecific T-wave flattening in leads V2, V3 and a VL. The EKG tracings were not overtly ischemic. The CPK enzymes are returning to normal thus far. The first CPK was 152. Patient now feels pain free, monitoring has shown normal sinus rhythm, and the patient’s vital signs have been stable.

Past Medical History: COPD with emphysema; noninsulin dependent diabetes mellitus; lupus erythematosis, 1948; prior appendectomy; 1963, partial gastrectomy, 1963.

Cardiac Risk Factors: Patient quit smoking 19 years ago. He stated that his cholesterol several years ago was in an excellent range. He had one uncle who had a heart condition but no immediate relatives have heart problems. This patient has never had a problem with hypertension.

Medication: Micronase 500 mg in the morning, 250 mg in the afternoon.

Physical Examination: This is a very pleasant black gentleman in no distress who is noted to be pain free. Vital Signs: BP 126/70, pulse 70, respiratory rate 16, temperature 36.4. HEENT: Atraumatic. Neck: The neck veins are flat. Thyroid: Normal. Lungs: Clear to auscultation. Cardiac Exam: Regular rhythm, no gallop or murmur. Abdomen: Soft nontender. Liver and spleen: Normal. Extremities: Warm. No edema present. Pulses: Normal. Neurologic: Gross neurological exam is unremarkable. Allergies: None.

Impression: The patient is a very pleasant 71-year-old gentleman who presents with chest discomfort, nonspecific EKG changes. Enzymes thus far are normal, and the etiology is undetermined. This possibly represents angina pectoris. Cardiac risk factors would include the history of diabetes mellitus and prior tobacco abuse.

Plan: The plan now is to rule out the MI protocol. If this is negative, then the recommendation for tomorrow is to proceed with a stress thallium study. Further recommendations will be based on the result of that testing. At this time, it is noted that the patient is pain free and has stable vital signs.

ICD-9-CM Code Assignments

786.50 Chest pain, unspecified

250.00 Diabetes mellitus without mention of complication, type II [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, not stated as uncontrolled

CPT Code Assignments

After going to the main listing for Evaluation and Management in the 2007 CPT manual index, you would look for consultation. Codes 99241-99255 are listed. After reading the descriptions for these codes, you will see that the following code (revised for 2007) is most appropriate for this cardiac consult (a professional service). Note that the American Medical Association revised this code for 2007.

99253 Inpatient consultation for a new or established patient

The following three key components are required to assign this code:

  • A detailed history
  • A detailed examination
  • Medical decision-making of low complexity

    Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit.

    Rationale for CPT Coding


  • History of present illness (HPI)–four elements
  • Review of systems (ROS)–three elements
  • Past family and social history (PFSH)–Complete with three elements


  • 12 bullets

    Medical Decision Making–High

  • One new problem with additional work-up
  • High overall risk
  • Limited data to review

    Julianne Seaman is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.

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