Oncology & Hematology Coding Alert

Determining the correct level of E/M services may sometimes resemble throwing darts at a board while blindfolded. With so much subjectivity, oncology practices should use a scoring system to ensure not only appropriate coding but uniform coding.
 
Scoring systems are not only used by hospitals and physician practices; they are also used by government auditors who look for inconsistencies in how providers code their E/M services, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm in Dallas, Ga.
 
While scoring systems can aid in choosing the appropriate visit level, a scoring system is not a substitute for good documentation, warns Dianna Hoffbeck, president of Northshore Medical, a coding consulting firm in Atlantic City, N.J. "You have to show the severity of symptoms and reveal the details of the visit," she says.
 
Despite CPT guidelines, some practices have difficulty choosing a level because the combination of history, exam and medical decision-making levels does not always coincide with the descriptors for E/M codes, such as 99211-99215 (established patient; office or other outpatient visit).
 
For example, an established patient with lung cancer who comes in for chemotherapy undergoes a problem-focused history and exam. During the exam, a new problem a side effect of chemotherapy is dis-covered, requiring complex medical decision-making. Should the visit be reported as a 99212 or should it be coded at a higher level?
 
Parman's scoring system is modeled after those used by auditors and quantifies all the elements involved in determining the E/M level. (See the scoring sheet inserts for new and established patients. They may also be found on our Web site at http://codinginstitute.com/docs, numbers 39 and 40.)

Documenting the History
 
 
The scoring system accounts for three elements:
 
1. History of present illness (HPI): During the visit or consult, oncologists may obtain one or more of the following regarding the patient's disease: location, quality, severity, timing, context, duration, modifying factors, and associated signs and symptoms.
 
Obtaining one to three equals a "brief" HPI, while four or more qualifies for an "extended" HPI. Because cancer is a potentially fatal disease, oncologists usually perform a detailed HPI, which requires them to cover four or more HPI elements.
 
"As a general rule, I can usually find extended history of present illness," Parman says.
 
2. Review of systems (ROS): Potential systems that may be reviewed are constitutional; eyes; ear, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; integumentary; musculoskeletal; neurologic; psychiatric; endocrine; hematologic/lymphatic; and allergies/immune system.
 
A ROS can be performed by a nurse, or patients may report their symptoms by completing a detailed questionnaire. ROS does not have to be performed by the oncologist, but he or she must review and sign the ROS, Parman says.
 
A single item qualifies as a "problem-pertinent ROS," two through nine equals an "extended" ROS, and 10 or more qualifies as a "complete" ROS.
 
3. Past, family and social history (PFSH): Asking the patient about past, family or social history constitutes "pertinent" PFSH; obtaining history regarding two of the three areas is also considered pertinent PFSH. If the oncologist obtains information about all three areas, he or she may report that a complete PFSH was performed.
 
On the score sheet, the coder should choose the appropriate descriptors for each of the above history elements. Using the lung cancer (ICD-9, 162) patient as an example, the physician checks the current location, severity, modifying factors and associated signs and symptoms an extended HPI. And the oncologist reviews the patient's respiratory and cardiovascular systems an extended ROS. Finally, the physician obtains the patient's social history, which categorizes it as a pertinent PFSH.
 
The score sheet aligns each of the history options with a set of characteristics drawn from each of the above elements. For example, a detailed history includes extended HPI and ROS, and pertinent PFSH. The score sheet should have the three areas circled, each circle corresponding with a level of history. The lowest element circled will drive the level of history. A detailed history may be reported in this case because a pertinent PFSH and extended ROS are the lowest elements and fall under detailed-history criteria.

The exam consists of the physician's investigating as many as 21 body systems. Examining only one system qualifies the exam as problem-focused, while two to seven systems equal extended problem-focused or detailed exam. The examination of eight or more systems allows the oncologist to report a comprehensive examination.
 
The similarity between extended problem-focused and a detailed examination calls for some subjectivity. To differentiate between the two, Parman advises coders to consider the quantity of work involved. Those that require more work to obtain a clear picture of a patient's health will likely qualify as detailed exams.
 
During the examination of the lung cancer patient described, the physician examined the respiratory system, cardiovascular system, abdomen and chest, equaling either an extended problem-focused exam or a detailed exam. Because the exam of systems mentioned yielded physician notes that describe the extensive examination rather than "systems normal" or "unchanged," the practice should be safe characterizing the exam as detailed.  
 
Medical Decision-Making 

Medical decision-making is determined through a combination of problem categories, the review of records and/or ordering of clinical laboratory tests, and the risk of morbidity and mortality.
 
Below are details from the exam of the lung cancer patient that will help determine the complexities of each of the three elements:

 

Diagnoses: Lung cancer and bone metastasis (170)
 

Management options: Surgery, chemotherapy, radiation therapy.
 

Complexity of medical records: Request copies of the patient record, which is in the custody of referring physician in another state; record shows history of diabetes (250.0) as well as primary cancer diagnoses and subsequent metastasis.
 

Tests: Magnetic resonance imaging (MRI), CT scan, bone scan.
 

Information reviewed: Reviewed most recent images, two CT scans.
 

Risk of complications: Complications include death from primary and secondary cancer diagnoses, as well as harmful side effects from radiation or chemotherapy treatment.
 

Explanation of risk and benefits: Physician spent one hour with patient discussing treatment options.
 

Counseling and coordination of care: Additional time spent with family members regarding findings and to review prognosis and discuss treatment options.
 
 
You can choose from five problem categories, with each reported problem assigned one point and a multiplier. The multiplier is factored in with the number of points in each category. The categories and their assigned multipliers are:
 

Self-limited or minor presenting problem  1 

Established problem; stable or improved  1

Established problem; worsening   2

New problem, no additional workup planned 3

New problem, additional workup planned  4
 
 
In the case of the lung cancer patient, there is one established problem. Because the cancer is worsening, evidenced by the bone metastasis, the physician can use the "established problem" category with a 2 multiplier, which gives the physician 2 points.
 
The recently diagnosed bone metastasis constitutes a new problem in which an additional workup is planned, which gives the physician another 4 points and a running total of 6 points.
 
Scoring the Data

Obtaining old records, discussing contradictory test results with the referring physician, and reviewing medical records helps the coder to determine the complexity of medical decision-making. Obtaining and reviewing old records or history from sources other than the patient increases the amount and complexity of reviewed data, Parman says. In the scoring system that she advocates, the following data review items are used to determine complexity of medical records by adding the number of assigned points:
 

Review and/or order clinical laboratory tests, 1 point
 

Review and/or order radiology tests, 1 point
 

Review and/or order tests from the Medicine Section of CPT, 1 point
 

Discuss diagnostic test results with performing physician, 1 point
 

Independent review of an image, tracing or specimen that has been previously interpreted by another physician, 2 points
 

Decision to obtain old records and/or obtain history from someone other than the patient, 1 point
 

Review and summarize old records and/or obtain history from someone other than the patient, 2 points.
 
 
Using the earlier example, the physician scores 6 points for ordering and reviewing radiology test (1 point), independent review of two images (4 points), and  obtaining old records (1 point).

The third element is risk of complications. Determining the difference between minimal-risk level and high-risk level requires an assessment of presenting problems, the diagnostic procedures ordered, and the chosen management options. For oncology physicians and oncology subspecialists, most cases will fall either in the moderate or in the high category. (See "Table of Risk" insert. This may also be found on our web site at http://codinginstitute.com/docs, number 41.)
 
In the clinical example being used, the patient's risk level is high in two of the three categories presenting problems and management options because the presenting problems pose a threat to life, and the management options include surgery and drug therapy that requires intensive monitoring for toxicity.
 
The problem categories and review of records and tests exceeded 4 points and the risk was scored as high, medical decision-making is therefore very complex. In this instance, all three fell in the highest medical decision-making categories. In cases where the levels of the three categories do not match, the level that coincides with two matching categories or the middle of three differing categories should determine the level of medical decision-making
 
Adding up the Score

Now it's time to add up the score. Based on scoring for history, you should have chosen "past family history," "extended past family history," "detailed history" or "comprehensive history." In the case described above, "detailed history" should have been chosen.
 
Scoring for the exam should have yielded a score between one and 21. That score should determine whether you choose problem-focused, extended problem-focused, detailed or comprehensive. In this case, "detailed" exam should have been chosen.
 
After weighing problem categories, laboratory tests ordered and reviewed, and the table of risk, you should have determined whether the complexity of decision-making is straightforward, low, moderate or high. In this case, "highly complex" is correct.
 
The possible choices for each of the three components are located at the bottom of the score sheet, three rows from left to right, from lowest to highest. The last row is for the five levels of E/M codes, also listed from left to right.
 
If a column above a specific E/M visit code identifies the levels of all three key components, that code should be used to report the level of E/M services. An established patient visit with three key components aligned above a single E/M code should be billed under that code. It is not always that simple. If two components are aligned with one E/M code, that code should be used. If the three components are spread out across the five levels, then the middle-level code should be chosen.
 
In the case of the lung cancer patient, a level-four E/M visit (99214) is appropriate because both detailed history and detailed exam fall under the 99214 column on the score sheet.