Oncology & Hematology Coding Alert

Using a scoring system is an effective way to reduce the subjectivity of determining the complexity of medical decision-making but if oncologists dont have the documentation to support high or moderate claims, there would be little choice but to characterize their medical decision-making as straightforward or of low complexity.

Oncology physicians often assume their specialty entitles them to characterize their medical decision-making as high in complexity. Yet, if faced with an audit, their documentation may not reflect the service they billed.

I had a neuro-oncologist tell me that everything he does is a level five, recalls Parman, CPC, CPC-H, principal of Coding Strategies, a coding consulting firm in Dallas, Ga. I said, Thats great if you have the documentation to prove it. He said, No, but because of my subspecialty all my cases require complex medical decision-making. It doesnt matter who you are, when an auditor comes in, he doesnt care if youre a primary-care physician or a neuro-oncologist, and he is going to apply the same requirements.

To properly document medical decision-making, Parman offers the following advice:

For a presenting problem with an established diagnosis, the medical record should reflect whether the problem is improved, well-controlled, resolving, resolved inadequately, controlled worsening or failing to change as expected. Problems that are improving or resolving are less complex than those that are worsening or failing to change as expected.

When a presenting problem is without a diagnosis, oncologists should state their clinical impressions in the form of a differential diagnosis or as possible, probable, or rule out diagnoses in the patient record. Diagnoses listed as possible, probable or rule out cannot be coded for the purposes of physician billing but contribute to the level of medical decision-making, Parman says.

A decision to obtain old medical records or history from sources other than the patient should be documented in the patient record along with relevant findings from these documents. Writing old records reviewed in the patients chart without elaboration is inadequate documentation, she says.

Personal review of lab, radiology or other diagnostic tests should be noted in the patients record along with notes from the discussion with the physician who performed or interpreted the tests.

The medical record should include documentation of co-morbidities and underlying diseases or other factors that increase the complexity of medical decision-making.