Oncology & Hematology Coding Alert

Question: A patient established with our office came to us complaining of fatigue. The patient’s cancer was in remission, and we had seen the patient a month earlier and everything was fine. The doctor spent 25 minutes with the patient during which he performed an exam and history and found nothing wrong. The note indicated the fatigue was not related to the patient’s prior cancer diagnosis and was probably due to the patient’s busy work schedule. Can we still get credit for the encounter since our provider found no problem, since we can no longer count exams and histories toward the office/outpatient evaluation and management (E/M) level?

Indiana Subscriber

Answer: You can — and should — get credit for this encounter, assuming your provider’s documentation supports it. Given that your provider examined the patient and would most likely take the patient’s cancer history into account, here’s how.

First, even though the provider has not provided a definitive diagnosis, you can still look for signs and symptoms in the note to use as justification for the visit. ICD-10-CM guideline I.B.4 tells you that “codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.”

That means a diagnosis of R53.83 (Other fatigue) would be acceptable to support the office visit E/M code.

Remember: As the provider determined the patient’s fatigue was not related to the patient’s cancer, now in remission, you would not use R53.0 (Neoplastic (malignant) related fatigue). Rather, you should assign a remission or history of cancer code (as appropriate) to document that the cancer was considered but not found to be the cause of the fatigue in support of the service level. So, if the patient had unspecified leukemia, now in remission, and that diagnosis was considered, but ultimately rejected as the fatigue’s cause, you could code R53.83 with C95.91 (Leukemia, unspecified, in remission).

This combination of diagnoses, supported by the visit note, should easily justify a low-level office/ outpatient E/M service code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …). You’ll calculate MDM as a self-limited or minor problem with no data and minimal risk of morbidity or mortality. However, this is an instance where you would be best served coding the E/M by time, as the 25 minutes your provider documented having spent with the patient would allow you to get credit for a higher — 99213 (Office or other outpatient visit for the evaluation and management of an established patient … When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) — service.