Oncology & Hematology Coding Alert

Check for new patient, detailed history, and ROS.

Choosing between Evaluation and Management (E/M) codes 99201  – 99205 may seem an arduous task. But you can master the skill by adopting a step-wise approach. Read this example and resharpen your E/M coding skills.

Scenario: The patient, who has had stage 1 grade 1 endometrial carcinoma three years ago, presents to your physician to seek an opinion on her current status. This patient underwent total abdominal hysterectomy, bilateral salpingo-oopherectomy and pelvic/peri-aortic lymphadenectomy 3 years ago. The current findings are as follows: 

• Elevated CA-125 levels in August of last year
• CT scan revealed enlarged retroperitoneal lymph nodes 
• PET scan evidenced FDG uptake in the retroperitoneal, periaortic, paracaval, right iliac and right internal lymph nodes

E/M Category: Confirm New patient

Your physician may document that a patient reports in his office for a second opinion. Additionally, you may read that the patient appeared in the office for the first time. The patient sought the second opinion at her own discretion. She was not referred by another physician for the second opinion.

In this case, you confirm the patient and presentation is new to the physician. You report this patient as a new patient. 

Tip: Do not report this visit as an office consultation. This is because the advice or opinion of the physician was not requested by another physician. The patient is seeking the physician’s opinion on her own. 

E/M Level: Check Details of History and Examination

You should confirm if your physician did a comprehensive history taking and examination for the patient. You may read that your physician assessed the duration, severity, and location of the patient’s carcinoma. Your physician may document the following;

“The patient presents for a second opinion after receiving diagnostic results from her oncologist.  Last year, the patient had elevated levels of CA-125. Since that time, she has remained asymptomatic of abdominal pain or genitourinary anomalies. A CT scan was performed revealing enlarged retroperitoneal lymph nodes. However at the time of the study, the nodes were not of a size to warrant a biopsy. This year CA-125 levels and a PET scan diagnostics were repeated. Results of the PET scan revealed FDG uptake in the retroperitoneal, paracaval, periaortic, right iliac, and right internal lymph nodes.” 

Read on further to check if your physician did a complete review of systems. 

Check Out This ROS Documentation

Your physician will document details of complaints relating to various orphan systems. Below is an example of a clinical note.

A review of systems revealed that the patient had hyperthyroidism, hypertension, hyperlipidemia, and diabetes mellitus type II. There was no history of varicose veins, chest pain, or difficult breathing. There was also no blurred or double vision and any other complaints relating to the eyes. There was no fever, chills, excessive fatigue, excessive thirst, headache, or weight loss. There was no ear infection or sore throat in the past. There is no history of urinary retention or excessive frequency of urination. There was no pain while urinating. The patient reports no rectal bleeding or black, tarry stools, easy bruisability, blood clotting problems, swollen glands, skin rash, boils, or itching. There is no back, joint, or neck pain. The patient denied any suicidal thoughts or ideations or chronic depression. The patient also denied any seizures, tremors, numbness, or dizzy spells. There was no hoarseness, wheeze, cough, or blood in sputum. 

Don’t Overlook Past, Social, and Family History Documentation

You should check if your physician has recorded the past, social, and family history for the patient. 

Your physician may document that the patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic/peri-aortic lymphadenectomy three years ago. In addition, he may make note of the medication that the patient is taking. You may spot the following in the clinical note:

• Calcium 1000 mg three times daily
• Fish oil 1000 mg twice daily
• Tolterodine tartarate LA 4 mg as needed
• Glipizide extended release 10 mg daily
• Metformin 1000 mg daily
• Lovastatin 40 mg daily
• Levothyroxine sodium 0.1 mg
• Vitamin E 200 mg daily

For social history, you may read in the clinical note about the habits and social engagements of the patient. For example, your physician may document the occupation of the patient and record the smoking and alcohol preferences as reported in the patient interview.

Lastly, you shall be able to spot the family history.

For instance, your physician may document that the patient reported her mother to have died of breast cancer. No other cancers were reported in the patient’s siblings. 

Editor’s note: Read more on physical examination, decision making, and diagnosis in the next issue of Oncology Coding Alert, Vol16n11.