Oncology & Hematology Coding Alert

Question: One of our providers always documents that his patients with an active cancer diagnosis have a chronic illness that poses a threat to life or bodily function even when the patient is doing well and stable on the current regimen. Does this mean that all cancer patients should be considered at the high level of medical decision making (MDM) for the number and complexity of problems addressed element in the MDM table?

AAPC Forum Participant

Answer: Even though a patient may have an active cancer diagnosis, this does not automatically make the MDM level high. More, an active cancer diagnosis does not automatically equate to any of the chronic illness levels.

Two of the office/outpatient evaluation and management (E/M) guidelines tell you why. First, the number and complexity of problems addressed MDM element also uses the words “at the encounter.” So, if the patient has a chronic illness that is stable at the time of the encounter (which CPT^® defines as when a patient is meeting their treatment goal), this MDM element only rises to the low level. So, a patient with an aggressive form of cancer who is meeting treatment goals at the time of a particular office/outpatient E/M service would be assigned a low level at that encounter, even if the goals were not met at a subsequent encounter.

Second, the CPT^® definition of a patient with a chronic illness or injury that poses a threat to life or bodily function notes that the threat must occur “in the near term without treatment.” In other words, the high level for the number and complexity of problems addressed MDM element is reserved for patients who are at a severe risk of mortality within a short timeframe of the encounter unless they receive treatment. A patient with aggressive cancer who is expected to live for some time, for example, would not rise to this high level, and neither would a newly diagnosed cancer patient with a slow form of the condition.