Oncology & Hematology Coding Alert

Fight the urge to code higher based on personal knowledge of the patient

CMS plans to raise the RVUs for 99214 by 9 percent next year, making it even more tempting to report higher-level E/M codes. But auditors love to target these codes, so you must be able to support your choice.

One of the key factors in determining which E/M code to report is medical decision-making (MDM). We-ve broken down the MDM requirements for 99214 and 99215 so you can code with confidence.

Stick to the rules: Don't expect shortcuts when assigning E/M levels, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, coding analyst with CodeRyte Inc. You have to look at the physician's documentation to determine the history, exam, and MDM levels, she adds.

For established patient E/M codes 99214-99215, you must meet the appropriate level for at least two of three requirements: history, examination, and MDM.

Assuming you-ve met either the history or exam requirements for 99214 (Office or outpatient visit for the evaluation and management of an established patient ... medical decision-making of moderate complexity ...) or 99215 (... medical decision-making of high complexity ...) and must now choose a code based on MDM, you must still consider a number of elements.

Take a look at the table on the following page, which you-ll find in both the 1995 and 1997 E/M Documentation Guidelines (www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp) and in the E/M guidelines in your CPT manual.

You must meet or exceed two of the three elements for a level to choose that MDM level. So, if the oncologist documents multiple management options and moderate risk of complication, but only a limited amount of data to be reviewed, you meet two of the three requirements for moderate MDM, which is sufficient.

Note: See the Clip and Save, later in this issue for details on how to calculate each category.

Example: An ambulatory established metastatic colon cancer patient with increasing fatigue arrives for his weekly 5FU therapy office visit.

The oncologist documents that the cancer is stable or improving while the fatigue is getting worse. This counts as multiple diagnoses. You check the table of risk and determine that the risk of complication is high.

Multiple diagnoses, no tests ordered or reviewed, and high risk suggest that this encounter qualifies as moderate MDM. You need to meet or exceed two of three requirements, so you eliminate the lowest, amount of data, which falls under minimum.

Although high risk falls under high complexity, multiple diagnoses only meets the moderate-complexity category, so you must choose moderate complexity.

Remember: Report the fatigue with its own diagnosis code (such as 780.79, Other malaise and fatigue), along with any other side effects or symptoms. Why? If the oncologist is treating multiple conditions, you should report multiple diagnosis codes -- just be sure the conditions are documented in the medical record.

Watch for This Chance to Boost MDM

Tell your physicians that they should clearly indicate when they-re taking an intermediate step that they don't believe will solve the patient's problem.

Explaining that they-re trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the MDM level, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, coding manager for the University of Washington's physician group in Seattle.

Documenting the extra step shows that the physician considered more management options (one element of MDM).

Avoid This Common Pitfall

MDM for oncology patients can be trickier than other specialties, so you have to keep in mind that E/M codes aren't based on the patient's diagnosis, says Beth Potratz, CPC-A, with the Cancer Treatment Center in Swansea, Ill. Don't code a higher level of decision-making than the documentation supports. 

Often, coders will boost the MDM because they know the patients are in really bad shape, Bucknam says. -They get emotionally involved in the complexity of the problem and don't code what the doctor wrote down,- she says.