Documentation Guidelines for Cardiology

1. Documentation Guidelines for Cardiology Medical Billers and Coders

2. Specifying anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects how physicians and clinicians communicate and to what they pay attention to – it is a matter of ensuring the information is captured in your documentation. In ICD-10-CM, there are three main categories of changes Definition Change; Terminology Differences; Increased Specificity. For cardiology, the focus is increased specificity and documenting the downstream effects of the patient’s condition.

3. Acute Myocardial Infarction (AMI) When documenting AMI, include the following:

4. Congestive Heart Failure The terminology used in ICD-10 exactly matches the types of CHF. If your document “decompensation” or “exacerbation,” the CHF type will be coded as “acute on chronic.” When documenting CHF, include the following:

5. Underdosing Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed. When documenting underdosing, include the following:

6. Atherosclerotic Heart Disease with Angina Pectoris When documenting atherosclerotic heart disease with angina pectoris, include the following:

7. Cardiomyopathy When documenting cardiomyopathy, include the following, where appropriate:

8. Proper documentation is critical to justifying medical necessity and the selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings, and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness, and accurate reporting of furnished services. Each office note must tell a complete story and be able to stand alone. Even small documentation errors can end up causing claims denials, and with all the voluminous claims filing that comes with cardiology billing and coding, it could be a good option for your practice to outsource your billing and coding. Through outsourcing, many cardiology practices are able to improve billing and coding efficiency so they’re able to spend more time focusing on offering patients quality patient care. Medical Billers and Coders (MBC) is a reputable medical billing and coding company that offers the highest quality service for clients across the country.

9. Get in Touch Medical Billers and Coders Email : info@medicalbillersandcoders.com Toll Free no: 888-357-3226