Wiki 99215 (High MDM)

[JMillett]

Hi Everyone - Wondering thoughts on the following scenario. Have a patient who has prostate cancer (c61) but based on note it is stable. Provider is ordering psa to watch levels and see if it is remaining stable. An auditor is indicating that it should be a level 5 because in complexity it is "1 chronic condition that places pt in danger/risk of life) Pt does not meet high for work performed but does meet for risk of complications. We are arguing that just because it "may" lead to risk of life does not mean it currently is.

 

[TThivierge]

JMillett
I always used CPT 99215 if patient told to go to ERM or became inpatient due to complex and dangerous illness. The auditor may feel since related to CA disease use this but I disagree . Adding that Prostate CA is slow growing cancer , plus it seems like follow up. Just my opinion.
I hope helped you
Lady T

 

[sls314]

I'd need to see the entire note for context, but I wouldn't automatically assign high for stable prostate cancer.

 

[amyjph]

Depends on the documentation. The fact that the patient has cancer does not automatically create a 5.

 

[deebizness]

Based on the information provided this does NOT satisfy the criteria for a 215.

 

[csperoni]

I also agree that cancer alone does not always create a level 5 problem. It depends where in their cancer journey they are. Surveillance visits for stable cancer patients are not level 5.

 

[kdlberg]

I would note that, clinically, prostate cancer is very slow progressing; a significant number of patients get minimal or no treatment other than monitoring, and can live another 10+ years, often dying of something else before the cancer metastizes and causes issues. Unless this patient is on a (documented) rapid decline or being evaluated for pallative care, I would not code a 5.