Oncology & Hematology Coding Alert

Question: What is the definition of treatment as it applies to the risk of complications and/or morbidity or mortality of patient management element of medical decision making (MDM)? What would not be regarded as treatment?

AAPC Forum Participant

Answer: CPT^® guidelines for office/outpatient evaluation and management (E/M) services provide the following definitions that you can use to determine if your provider is, or is not, treating a patient for a given condition, enabling you to evaluate the level of MDM for the risk of complications element:

• The problem must be “treated at the encounter by the physician or other qualified health care professional [QHP] reporting the service.”
• The treatment “may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.”
• “Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment) does NOT qualify as being addressed or managed by the physician or other qualified health professional.”

From this, and from the examples listed in the MDM table, you can logically evaluate the treatment risk level whenever your provider considers managing a patient’s condition at a specific encounter with drug management/therapy and/or procedures including surgery, whether or not the provider, patient, or patient guardian decides to proceed with that treatment. This column of the MDM table also lists the following which would cause treatment risk level to rise to either moderate or high risk: treatment significantly limited by social determinants of health, drug therapy requiring intensive monitoring for toxicity, decision regarding hospitalization, or decision not to resuscitate or to de-escalate care because of poor prognosis.

In 2021, CPT^® removed treatment examples from the risk column for the minimal and low levels. This was done to give provider’s more control over the determination of risk level for each individual patient as treatment for one patient could be considered low, whereas the same treatment for another patient could be considered moderate depending on patient-specific health status. Clear documentation from your provider will be key when determining the level of treatment risk.

Remember: You determine the level for this element of MDM by the risk of complications that the treatment could potentially cause, not by the complications the course of treatment actually produces once enacted.