What CPT codes are used for cardiology consultations?

Use new patient E/M codes 99202-99205 for outpatient consultations (consultation codes 99241-99245 are not recognized by Medicare). For inpatient consultations, use initial hospital care codes 99221-99223. Select level based on MDM complexity or total time documented.

How should I document cardiovascular risk factors?

Document all major CV risk factors: hypertension (control status), diabetes (A1c), dyslipidemia (lipid panel values), smoking (pack-years, quit date), obesity (BMI), family history of premature CAD, and sedentary lifestyle. Calculate and document 10-year ASCVD risk score when appropriate.

What cardiac testing should be documented in the consultation?

Review and document prior ECG (rhythm, intervals, ST changes), echocardiogram (EF, wall motion, valves, diastolic function), stress testing (protocol, results, Duke score), cardiac catheterization if performed, and any cardiac imaging (CT calcium score, cardiac MRI). Note dates and key findings.

How do I document NYHA functional class appropriately?

NYHA Class I: No limitation, ordinary activity causes no symptoms. Class II: Slight limitation, comfortable at rest, ordinary activity causes symptoms. Class III: Marked limitation, comfortable at rest, less than ordinary activity causes symptoms. Class IV: Unable to carry on any activity without symptoms, symptoms at rest.

What should a cardiology consultation letter include?

Include: reason for consultation, summary of cardiac history and risk factors, current symptoms, relevant exam findings, interpretation of diagnostic studies, assessment with specific diagnoses, and clear recommendations for management. Copy the referring physician and document communication in the note.

Cardiology New Patient Consultation Template

Consultation Information

Referring physician: [Name, practice]
Reason for referral: [Chief complaint or question]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary cardiac concern]
Duration: [Onset, timeline]
Current status: [Stable / Worsening / Improving]

History of Present Illness

[Detailed narrative of current cardiac concerns]
Symptoms review:

Chest pain/discomfort: [Character, frequency, triggers]
Dyspnea: None / Exertional / Rest / Orthopnea / PND
Palpitations: None / [Frequency, duration, triggers]
Syncope/presyncope: None / [Details]
Edema: None / [Location, severity]
Fatigue: None / [Impact on activity]

Functional capacity:

NYHA Class: I / II / III / IV
METs: [Estimated activity tolerance]
Exercise tolerance: [Flights of stairs, blocks walked]

Cardiac History

Coronary artery disease: None / [Details: MI, PCI, CABG dates]
Heart failure: None / [HFrEF, HFpEF, EF if known]
Arrhythmias: None / [AFib, flutter, VT, pacemaker/ICD]
Valvular disease: None / [Valve affected, severity]
Congenital heart disease: None / [Details]
Peripheral vascular disease: None / [Details]
Prior cardiac procedures: [List with dates]
Prior cardiac imaging: [Echo, stress test, cath dates and results]

Cardiovascular Risk Factors

Hypertension: Yes / No — Duration: [X] years, Control: [Good/Poor]
Diabetes: Yes / No — Type [1/2], Duration: [X] years, A1c: [X]%
Hyperlipidemia: Yes / No — LDL: [X], on statin: Yes / No
Smoking: Current / Former ([quit date]) / Never — Pack-years: [X]
Family history premature CAD: Yes / No — [First-degree relative <55M/<65F]
Obesity: Yes / No — BMI: [X]
Sedentary lifestyle: Yes / No
Chronic kidney disease: Yes / No — GFR: [X]
Sleep apnea: Yes / No — On CPAP: Yes / No

Current Medications

Cardiac medications:

[Medication, dose, frequency]

Other medications:

[List relevant medications]

Allergies

[Drug allergies and reactions]

Social History

Tobacco: [As above]
Alcohol: [Quantity, frequency]
Recreational drugs: [If applicable]
Exercise: [Type, frequency, limitations]
Occupation: [Relevant exposures or demands]

Physical Examination

Vital signs: BP [X/X] (R arm), HR [X], RR [X], SpO2 [X]%, Weight [X], BMI [X]
General: [Appearance, distress level]
HEENT: [JVP assessment]

JVP: [X] cm above sternal angle / Not elevated

Cardiovascular:

Carotid pulses: Normal / Bruit [R/L] / Diminished
PMI: Normal / Displaced [location]
Heart rhythm: Regular / Irregular
Heart sounds: S1 [normal/diminished], S2 [normal/split/loud]
Extra sounds: None / S3 / S4
Murmurs: None / [Grade I-VI/VI, location, timing, radiation]
Rubs: Absent / Present

Lungs: Clear bilaterally / Rales [location] / Wheezes / Decreased breath sounds
Abdomen: Soft, non-tender / Hepatomegaly / Ascites
Extremities:

Edema: None / [Grade +1 to +4, location]
Pulses: Femoral [2+/R, 2+/L], DP [2+/R, 2+/L], PT [2+/R, 2+/L]
Clubbing/cyanosis: Absent / Present

Diagnostic Data Review

ECG: [Rate, rhythm, intervals, axis, ST-T changes, interpretation]
Prior echocardiogram: [Date, EF, valve function, wall motion]
Prior stress test: [Date, type, result, ischemia]
Prior catheterization: [Date, findings]
Labs: [Relevant: lipid panel, BMP, BNP, troponin]

Assessment

1) [Primary cardiac diagnosis] — [Severity, stability]
2) [Secondary cardiac diagnosis if applicable]
3) [Relevant comorbidities affecting cardiac care]
Risk assessment: [ASCVD risk score if applicable]

Recommendations

1) Diagnostic workup:

[ECG, echo, stress test, Holter, etc.]

2) Medical therapy:

[Medication recommendations with rationale]

3) Risk factor modification:

[BP goal, lipid goal, diabetes management, smoking cessation]

4) Lifestyle modifications:

[Diet, exercise, weight management]

5) Procedures: [If indicated]

[Catheterization, ablation, device, etc.]

6) Follow-up:

Cardiology: [Timeframe]
Return to referring physician for: [Ongoing management items]

Communication

Discussed findings and recommendations with patient.
[Copy to referring physician: Yes]

Patient Education

Cardiac risk factors, medication purposes and side effects, warning symptoms requiring urgent evaluation, lifestyle modifications.

Cardiology — New Patient Consultation Template

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