Oncology & Hematology Coding Alert

Physical examination and physician decisions are key to correct coding.

In the last issue of Oncology Coding Alert, Volume 16 Number 10, you read how history was elemental in E/M coding. Further steps to the right E/M codes include scrutinizing the details of physical examination and checking what your physician eventually concludes. Lastly, diagnosis coding helps to explain why the visit occurred, support medical necessity and make your claim complete. We follow the example of the patient with endometrial carcinoma with elevated CA-125 that we discussed in the last issue to further describe how you can strengthen your E/M coding skills.

Enlist All Details of Physical Examination

Look for the physical examination that your physician performed for the patient. Also make note of the general examination and the organ systems that your physician examined. Below are some details which can help you confirm the physical examination that your physician performed.

“The patient appears healthy, alert, and oriented. The pulse, blood pressure, respiration are normal. There are no findings on inspection and palpation of the abdomen. There is no icterus on the sclera. There is no cervical, supraclavicular, axillary, or inguinal lymphadenopathy. There is no pallor or edema. Hearing is normal. No abnormalities detected on examination of the nose, throat, and mouth. Neck appears normal. No thyroid enlargement detected.

Cardiovascular system: The heart rate was normal and the rhythm was regular. No murmur, gallop, or rub detected.

Respiratory system: Lungs are clear. There are no rales, rhonchi, or wheezes. There is no dyspnea.

Abdomen is soft, no tenderness detected in any of the four quadrants. Bowel sounds normal. There is no organomegaly.

Nervous system: There are no neurological deficits and the patient has normal judgment, mood, and memory. There is no gait abnormality. There is normal range of motion, stability, and strength.”

The above example explains a comprehensive physical examination.

Check What Your Physician Concludes

To be able to report the correct E/M code, you should never miss the assessment and impression your physician documents for the patient. Accordingly, you report from codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components……Typically, 10 minutes are spent face-to-face with the patient and/or family) – 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…..Typically, 60 minutes are spent face-to-face with the patient and/or family). 

For the patient being discussed, you can confirm that the patient is a survivor of stage IB, grade I endometrial adenocarcinoma. She has now been detected enlargement of retroperitoneal nodes and elevation in CA-125. This most likely seems to be a recurrent endometrial carcinoma. 

In this case, however, your physician suggests that the patient returns after 3 months when it would be advisable to repeat CA-125 and also do a CT scan or a PET scan. The enlarged lymph nodes are not big enough for a biopsy currently. Your physician may conclude that the patient can be followed up on observation and chemotherapy may be later initiated if the carcinoma progresses. 

Define the decision making: In this example, you learn that the patient presents to your physician for the first time, your physician reviews laboratory and radiology tests. Eventually, your physician advises observation. This involves moderate decision making. You hence report E/M code 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…Typically, 45 minutes are spent face-to-face with the patient and/or family).

Dive Deep for Diagnosis Coding

You must also assign the ICD-9-CM codes supported by the documentation. The patient has high CA-125. You report ICD-9-CM code 795.82 (Elevated cancer antigen 125 [CA125]). You also read that your physician documented enlarged lymph nodes detected on the radiological investigations. For this diagnosis, you report code 785.6 (Enlargement of lymph nodes). For personal history of carcinoma of the endometrial lining of the uterus, you report code V10.42 (Personal history of malignant neoplasm of other parts of uterus). From the last issue, you may also remember the physician documented a family history of breast cancer in the patient’s mother.  Therefore, you would also report V16.3 (Family history of malignant neoplasm of breast).