Oncology & Hematology Coding Alert

Key: A review of history determines the type of code to use.

Office visits are where the oncological roadmap begins, and if you code these encounters incorrectly, auditors will make you start over at square one. Avoid these setbacks by mastering the three factors that determine which code you should use.

First, know your codes:

• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.)
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services)

Most office visits descriptors mention history, examination, and decision making. But these factors can be confusing. Each factor involves varying degrees of complexity that can impact your decision about which code is appropriate for each office visit.

1. Take A Closer Look at History

When your oncologist takes a patient’s history, she reviews the circumstances of a patient’s illness, from the onset of the problem to the present. The E/M guidelines break up history into four distinguishable categories. First and foremost you must have a chief complaint. Then the other three categories require a standardized number of elements for the History of Present Illness (HPI), Review of Systems (ROS) and a certain number of the review of Past Medical, Family, and/or Social History (PFSH).

Chief complaint: All E/M visits must contain a chief complaint. This statement justifies the rationale and focus of the visit.

HPI: Next, a review of the HPI includes questioning the patient regarding the following components of an illness or injury:

       1.) Location
       2.) Quality
       3.) Severity
       4.) Duration
       5.) Timing
       6.) Context
       7.) Modifying Factors
       8.) Associated Signs/Symptoms

For an established patient presenting with chronic issues, documentation of the status of at least three will qualify the visit for an extended HPI, which is equivalent to documenting four of the components listed above.

ROS: The systems included in the ROS include:

       1.) Constitutional
       2.) Eyes
       3.) Ears, nose, mouth, throat
       4.) Cardiovascular
       5.) Respiratory
       6.) Gastrointestinal
       7.) Genitourinary
       8.) Musculoskeletal
       9.) Integumentary
       10.) Neurological
       11.) Psychiatric
       12.) Endocrine
       13.) Hematologic/Lymphatic
       14.) Allergic

Remember for oncology coding, you will not be using some of these ROS, however make sure you are familiar with the ones that are relevant to your visit.

PFSH: The PFSH includes:

Past Medical History, which may include, but not be limited to:

       1.) Prior illness or injuries
       2.) Prior operations
       3.) Prior hospitalizations
       4.) Current medications
       5.) Allergies
       6.) Age appropriate immunization status
       7.) Age appropriate feeding/dietary status

Family History which includes items such as:

       1.) The health status or cause of death of parents, siblings, and children
       2.) Specific diseases related to problems identified in the chief complain, HPI, or ROS
       3.) Diseases of family members which may be hereditary or place the patient at risk

Social History which includes information such as:

       1.) Marital status/living situation
       2.) Current employment
       3.) Occupational history
       4.) Use of drugs/alcohol
       5.) Level of education
       6.) Sexual history
       7.) Other relevant social factors

Familiarizing yourself with these ROS and PFSHs will make it easier for you to identify which of the four degrees of history is the appropriate level to use. The requirements listed for the following four levels of history are for a new patient:

• Problem Focused History: This is the lowest level of history, which provides the least amount of a patient’s details. For this level of history, 1-3 HPI components are documented, however, ROS and PFSHs are not required.
• Expanded Problem Focused History: To qualify for this level of history, 1-3 HPI components are required here as well as one ROS. No PFSH is necessary for this level.
• Detailed History: This level of history requires significantly more material than the previous two levels. A Detailed History needs to have 4 or more HPI components, two to nine ROS plus one element from the PFSH.
• Comprehensive History: The comprehensive history is the most detailed level of history. This requires 4 or more HPI components, 10 ROS plus a complete review of all elements of the PFSH.

If you can identify all the elements that make up a history, you can more accurately determine what level of history the oncologist performed.

2. Go In-Depth with the Examination Documentation

Examinations, like history, have a series of elements that must be referred to if you are going to code correctly. In this case, a certain number of organ systems or body areas must be examined to justify use of a specific level of examination.

These organ systems are:

       1.) Constitutional
       2.) Eyes
       3.) Ears, nose, mouth, and throat
       5.) Respiratory
       6.) Cardiovascular
       8.) Gastrointestinal
       9.) Male genitourinary
       10.) Female genitourinary
       11.) Lymphatic, Hematologic, Immunologic
       12.) Musculoskeletal
       13.) Skin
       14.) Neurologic
       15.) Psychiatric

The body areas are:

       1.) Head
       2.) Neck
       3.) Abdomen
       4.) Chest
       5.) Back
       6.) Genitalia
       7.) Extremities

Each organ system breaks down into more specific bullets that identify procedures performed by the oncologist. Keep in mind that the number of organ systems and the number of bullets determines the level of examination using the E/M 97 guidelines.

Also similar to the history component, using the 97 guidelines, examinations are divided into four categories that can be properly identified if you refer to the number of organ systems examined:

• Problem Focused Examination: The lowest level of examination requires 1-5 bullets from one or more organ systems to justify this degree of examination.
• Expanded Problem Focused Examination: This level requires at least 6 bullets from any organ systems.
• Detailed Examination: This level requires two bullets from 6 organ systems or 12 bullets from two or more organ systems.
• Comprehensive Examination: This level requires 2 bullets from every organ system identified in the above list.

Utilizing the E/M 1995 guidelines, the following is true:

• Problem Focused Examination: The lowest level of examination requires one organ system or body area be examined.
• Expanded Problem Focused Examination: This level requires examination of 2-7 organ systems or body areas.
• Detailed Examination: This level also requires examination of 2-7 organ systems or body areas, however, at least one of the examinations must be in greater detail in an area focused on the problem being evaluated.
• Comprehensive Examination: This level requires examination of 8 or more organ systems or body areas.

Be sure to check with your carrier before combining organ systems and body areas as only certain carriers allow them to be combined when using 95 exam guidelines.

Keep in mind: You need to use either the 95 or 97 guidelines; you cannot merge the two.

3. Count Your Points for Medical Decision Making

Knowing the level of medical decision making can make your coding a whole lot easier. The American Medical Association (AMA) states that decision making determines how sophisticated the process for determining a diagnosis or selecting a management option will be. This is determined by a variety of factors, including the number of possible diagnoses, the complexity diagnostic tests, and the risk involved in potential procedures.

To understand what level of decision making is appropriate to code, you must understand the definitions of problem points and data points. These factors help you pinpoint exactly what level is appropriate.

Problem points are identified as a system of compiled points based on the severity of a problem. Refer to the bullets below to see what level of problem correlates to what number of points:

• Minor Problem: 1 point (with a maximum of 2)
• Improving/Stable, Established Problem: 1 point
• Worsening, Established Problem: 2 points
• New Problem with No Additional Work Planned: 3 points (with a maximum of 1)
• New Problem with Additional Work Planned: 4 points

Data points are the second factor required to properly identify the decision-making level. Like problem points, data points are calculated numbers based on the level of data. Refer to the bullets below:

• Review/order of lab tests: 1 point
• Review/order of radiology test: 1 point
• Review/order of medicinal test: 1 point
• Discussion of test with performing physician: 1 point
• Obtain old records: 1 point
• Review of old records: 2 points
• Independent review of image or specimen: 2 points

In addition to problem points and data points, risk must also be determined. There are four levels of risk: minimal, low, moderate and high. Risk level is chosen based on the Presenting Problems, the Diagnostic Procedure(s) Ordered and Management Options Selected. The overall measure of risk is the highest level chosen from any category on the table.

Master these elements and you will easily determine the level of decision making used, which in turn, will help you identify the proper code to use. Decision making is broken down into four categories:

• Straightforward Decision Making: Requires one or no problem points, one or no data point and minimal risk.
• Low Complexity Decision Making: Requires two problem points, two data points and low risk.
• Moderate Complexity Decision Making: Requires three problem points, three data points and moderate risk.
• High Complexity Decision Making: Requires four or more problem points, four or more data points and high risk.

Of note, only two requirements of each decision-making level must be met (or exceeded) in order to choose the overall level. For example, if three problem points, no data points and moderate risk is met, the overall medical decision-making level is moderate. Alternatively, if one problem point, two data points, and moderate risk is documented; your overall level of decision making is low because two data points were met and low risk was exceeded.

Once you identify the level of history, the level of examination, and the level of decision making, choose the correct code based upon the score in each section (history, exam and medical decision-making) and identify the level the office visit supports.