Oncology & Hematology Coding Alert

Don't forget to check the table of risk before you code

Get out your calculators -- coding medical decision-making (MDM) requires you to put your math skills to use. Match up the points in each category to determine the level of each MDM requirement.

1 point = minimal, 2 points = limited, 3 points = multiple, 4 points = extensive

Diagnosis and Treatment:

- Self-limited or minor problems (1 pt, max 2) ___

- Each established problem/stable or improving (1 pt) ___

- Each established problem worsening (2 pts) ___

- A new problem/no additional workup planned (3 pts, max 1) ___

- New problem/additional workup planned (4 pts) ___

- Total: _______

- Assigned diagnosis and treatment option level: ______

Amount and Complexity of Data:

- Review and/or order of clinical lab tests (1 pt) ___

- Review and/or order of tests in radiology section (1 pt) ___

- Review and/or order of tests in medicine section (1 pt) ___

- Discussion of test results with performing physician (1 pt) ___

- Decision to obtain old records or obtain history from someone other than patient (1 pt) ___

- Review and summarization of old records or obtaining history from someone other than patient or discussion of case with another healthcare provider (2 pts) ___

- Independent visualization of image, tracing, or specimen itself (not simply review of report) (2 pts) ___

- Total: _______

- Assigned complexity level: _______

Risk of Significant Complications:

Minimal             Moderate
Low                    High

See the Table of Risk on page 14 of the 1995 E/M Guidelines (www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf) or page 52 of the 1997 Guidelines (www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf).