Oncology & Hematology Coding Alert

Question: If a patient has a cancer diagnosis, should be that be counted as an “acute or chronic illness or injury that poses a threat to life or bodily function … in the near term without treatment,” per the CPT^® definition? We have new AI software that is not catching this.

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Answer: Any diagnosis, even cancer, does not automatically translate to a specific level of medical decision making (MDM). The level depends on the status of the problem and decisions and treatment as documented at the time of the encounter. Patients with a cancer diagnosis who are currently experiencing a good response to their treatment without side effects and no need for a change to the care plan, for example, may not rise to even reporting an E/M level on days where treatment is being performed or on days without treatment. In such cases, a high level of the Number and Complexity of Problems Addressed element of MDM would not be supported.

Consider the following levels of the problem element of MDM produced by similar encounters with breast cancer patients who previously had a partial mastectomy, who are now in remission, but who are experiencing different reactions to medication they are currently taking for the condition.

Example 1: A breast cancer patient had a partial mastectomy two years ago. She has been on tamoxifen without side effects, and there is currently no evidence of disease.

This patient’s condition would be regarded as a chronic condition that is currently stable, so the problem element level of MDM would be low.

Example 2: A breast cancer patient had a partial mastectomy two years ago. She has been on tamoxifen with minor side effects of hot flashes. There is currently no evidence of disease.

This patient’s condition would be regarded as a chronic illness with exacerbation, progression, or side effects of treatment, so the problem element level of MDM would be moderate.

Example 3: A breast cancer patient had a partial mastectomy two years ago. She has been on tamoxifen that is causing severe hot flashes, night sweats, and edema. There is currently no evidence of disease.

This patient’s condition would be regarded as a chronic illness with severe exacerbation, progression, or side effects of treatment, so the problem element level of MDM would be high.

The bottom line: While a cancer diagnosis might be high level problem, if there are no condition changes, new plans, or treatment changes, the diagnosis will more than likely translate to a lower-level problem element of MDM.