Gastroenterology Coding Alert

Question: Our gastroenterologist attended to a patient and noted the following:

Assessment: 1.Rectal bleeding, Likely hemorrhoidal; 2.External hemorrhoids; 3.Internal hemorrhoids; 4.Diverticulosis, colon; 5.Benign neoplasm, colon; Three TA on path. Good prep.

Instructions: Colon recall in 3 years unless new symptoms; High fiber diet recommended; Increase fluid intake; Call for abdominal pain with fevers, chills or rectal bleeding; Sitz/warm baths 1-2 daily; Anusol cream BID x 7 days; Philips gummy.

Please tell me what level of Medical Decision Making you would audit this as?Can two or more stable chronic illnesses (diverticulosis and hemorrhoids) constitute moderate MDM?

Arizona Subscriber

Answer: The information you provide appears to be the Assessment and Instructions from a colonoscopy or sigmoidoscopy report and not part of an office visit note and, therefore, would not be separately billable from the procedure itself. If this is from a different day than the procedure then you have not made that clear, and therefore the question is not answerable on current information.

However, if there was a similar Assessment and Instructions from a purely office visit then the medical decision making for the documentation that is provided would be low. Assuming that this is an established patient, the number of diagnoses or treatment options would allow only five points. This would equate to extensive for this section. The presenting problems are minor and the management options are low as well. There is no information regarding data reviewed or ordered in the documentation so there would be no points assigned in the reviewed data section. The overall level of medical decision making would be low. 

Please see below for a sample audit worksheet which can be used to determine levels.

http://can.communityoncology.org/UserFiles/files/CMSAuditToolfromHGSA.pdf

For the documentation that was provided, there is no indication that the problems are chronic and that they are unstable or that the patient is having complications from the conditions. Therefore, moderate MDM will not be applicable here. 

Note: You have to look at the description of problem vs. illness for calculating the level. Think of low as a minor problem or a stable chronic illness such as hypertension or diabetes and moderate as a chronic illness (hypertension or diabetes) with complication or mild exacerbation.