E/M Coding Helper for Cardiology Visits

This tool guides you through assessing MDM for inpatient (99221-99223, 99231-99233) or outpatient (99202-99205, 99212-99215) cardiology visits.

Step 1: Encounter Type

Select the type of encounter:

Step 2: Visit Type

Select the type of visit:

Step 3: Number and Complexity of Problems Addressed

Select the option that best matches your encounter. Examples are provided for each level.

Low Level

1 self-limited or minor problem (e.g., palpitations resolved with reassurance)
Or 2+ self-limited/minor problems
Or 1 stable chronic illness (e.g., controlled hypertension)
Or 1 acute, uncomplicated illness/injury (e.g., mild chest discomfort, likely musculoskeletal)

Moderate Level

1+ chronic illnesses with exacerbation/progression/side effects (e.g., worsening angina requiring medication adjustment)
Or 2+ stable chronic illnesses (e.g., hypertension and stable CAD)
Or 1 undiagnosed new problem with uncertain prognosis (e.g., new exertional dyspnea)
Or 1 acute illness with systemic symptoms (e.g., suspected pericarditis)
Or 1 acute complicated injury (e.g., chest trauma in patient on anticoagulants)

High Level

1+ chronic illnesses with severe exacerbation/progression/side effects (e.g., heart failure with worsening dyspnea requiring urgent intervention)
Or 1 acute/chronic illness/injury threatening life or function (e.g., suspected acute coronary syndrome)

Please select an option to proceed.

Step 4: Amount and/or Complexity of Data Reviewed and Analyzed

Check all that apply. The level will be determined based on categories met.

Category 1: Tests, Notes, and Historian

Review of external notes from unique source
Review of unique test results (e.g., reviewing prior echocardiogram)
Ordering of unique tests (e.g., order a stress test, order a coronary CTA with contrast)
Assessment requiring independent historian (e.g., family input for confused patient; qualifies as Low level if selected alone)

Category 2: Independent Interpretation

Independent interpretation of tests not separately reported (e.g., personally reviewing an ECG or stress test)

Category 3: Discussion

Discussion with external provider/source (e.g., consulting cardiothoracic surgeon)

Levels:

Low: Minimal or limited (e.g., any 2 from Category 1 or independent historian)
Moderate: Moderate (e.g., any 3 from Category 1, or Category 2, or Category 3)
High: Extensive (meet 2 of 3 categories)

Step 5: Risk of Complications and/or Morbidity or Mortality

Select the option that best matches. Examples included.

Low Level

Minimal (e.g., lifestyle modification, over-the-counter meds)
Or low (e.g., prescribing low-dose aspirin)

Moderate Level

Prescription drug management (e.g., initiating or adjusting statins or beta-blockers)
Decision for minor procedure with risk factors (e.g., cardioversion in anticoagulated patient)
Treatment limited by social determinants (e.g., non-compliance due to financial barriers)
Ordering a cardiac stress test (e.g., treadmill or nuclear stress test for suspected CAD)
Ordering a coronary CTA with contrast (e.g., to evaluate for coronary artery disease)

High Level

Drug therapy needing intensive monitoring (e.g., initiating amiodarone with close follow-up)
Decision for major procedure with risk factors (e.g., planning cardiac catheterization in high-risk patient)
Decision to refer for urgent hospitalization (e.g., suspected unstable angina requiring inpatient evaluation)

Please select an option to proceed.

Step 6: Time Override (Optional)

If using time instead of (or in addition to) MDM, enter total minutes spent on the date of encounter (includes chart review, counseling, etc.).

Total minutes (e.g., 30):

Please enter a valid non-negative number.

Thresholds:

Results

This is an educational tool only. Consult official guidelines and your billing team.

For full details: AMA Guidelines