Wiki Comprehensive Hx/Exam overriding MDM

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tfischer

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We have an Oncologist that is fairly new to our physician group. As you already know, this specialty is very unique from all other specialties. I'm hoping to get some insight from an Ohio coder to make sure we are capturing everything.

For established patient visits: Even though the patient really is HIGH risk because they have Stage IV lung cancer and receiving Chemo, the MDM is not meeting a high level complexity. Simply because the patient only has 1 problem and not enough data is being done to obtain a high risk MDM. In my opinion this is not fair to the physicians, because there is a lot of work put into the decisions and treatments of these patients. So my question is, what levels are your Oncologists assigning? If they are assigning 99215's, are you giving them credit if a Comprehensive History and Examination is documented? I know Medicare has this whole 'medical necessity' thing. But again, I truly do not think it's fair to the physician. The CPT/AMA states 2/3 components for an established patient.

If someone could please answer the above question, and/or send additional information regarding the above or other information pertaining to Oncology I would greatly appreciate the help. We only want to make sure we are not missing anything.

Thank you for any help!! :eek:
 
tfischer said:
We have an Oncologist that is fairly new to our physician group. As you already know, this specialty is very unique from all other specialties. I'm hoping to get some insight from an Ohio coder to make sure we are capturing everything.

For established patient visits: Even though the patient really is HIGH risk because they have Stage IV lung cancer and receiving Chemo, the MDM is not meeting a high level complexity. Simply because the patient only has 1 problem and not enough data is being done to obtain a high risk MDM. In my opinion this is not fair to the physicians, because there is a lot of work put into the decisions and treatments of these patients. So my question is, what levels are your Oncologists assigning? If they are assigning 99215's, are you giving them credit if a Comprehensive History and Examination is documented? I know Medicare has this whole 'medical necessity' thing. But again, I truly do not think it's fair to the physician. The CPT/AMA states 2/3 components for an established patient.

If someone could please answer the above question, and/or send additional information regarding the above or other information pertaining to Oncology I would greatly appreciate the help. We only want to make sure we are not missing anything.

Thank you for any help!! :eek:
Click to expand...

My question is are you physicians documenting the time element? I used to work in Oncology in Baltimore MD and I understand what you are saying. Is the patient by chance going to receive Chemo on this visit date by this same provider? I know, in my cases the providers were spending alot of time in counseling with the patient and the family members during the visit. You are right, CPT does states 2/3 components must be met in order to qualify for any level of established visit. Just make sure your carrier isn't one that requires it be history/MDM, I've heard some coders who have carriers that designate which 2 of the 3 components must be met.

Would you mind "sanitizing" this note for us?

I really do feel for you because I used to go thru the same thing when I coded Oncology.
 
I absolutely understand what you're talking about, because we have the same issue with our oncologists.

We have to be careful not to confuse MDM with "medical necessity". Medical necessity is the overriding factor for code selection, and in most cases, MDM is the best way to determine necessity. However, if your detailed History and Exam support the medical necessity of a higher LOS, even though you have a straightforward or low MDM (lung cancer), then you have a very solid argument for the higher code. Be careful not to just count bullets....in this case, the HPI, ROS, PFSH and Exam components must all relate to the re-evaluation of the lung cancer. If not...it won't meet the 'medical necessity' sniff-test.

I'll probably get flamed for this rationale...becasue so many coders love the black & white! But I would argue this scenario as being correct coding. Welcome to the world of gray!

have a good weekend. Pam
 
Medical Necessity

Thank you both so much for replying. It makes me feel better that I'm not the only one suffering in this area.
 
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