Oncology & Hematology Coding Alert

To ensure your evaluation and management (E/M) service charges are safe from auditor scrutiny, oncologists should use the same method to determine the complexity of medical decision-making as the auditors use, says Cindy Parman, CPC, CPC-H, principal of Coding Strategies, a coding consulting firm in Dallas, Ga.

Auditors, who are generally FBI agents with limited clinical knowledge, use a scoring system to determine whether the services provided justify the complexity of medical decision-making a physician claims when he or she bills for an E/M service. Most physicians, however, do what I call the coding dance, says Parman, who is on the American Medical Associations (AMA) CPT faculty and has radiation oncology practices as clients. They apply an E/M code that feels right.

Sally Trew, RN, CPC, a medical reimbursement consultant with Alpern, Rosenthal & Company, a Pittsburgh, Pa., accounting firm that provides healthcare consulting services, agrees. If you dont use a scoring system, youre putting yourself at risk of upcoding and having to pay back money and being assessed fines, Trew says.

Medical decision-making refers to the complexity of establishing a diagnosis or selecting treatment options, or both. CPT 2000 instructs physicians to use the following three areas to help determine the complexity of medical decision-making:

The number of possible diagnoses and/or the number of management options that must be considered;

The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and

The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities associated with the patients presenting problem, the diagnostic procedures and/or the possible management options.

To characterize medical decision-making as highly complex, physicians need to prove two of the following: extensive number of diagnoses or management options; extensive review of data; or high risk of complications, morbidity or mortality. To prove moderate complexity, physicians must show two of the following: multiple diagnoses or treatment options; moderate review of data; and moderate risk of complications.

Its very subjective, says Parman. There could be better definitions. A scoring system is the best way to take the guess work out, she says. She recommends using the same scoring system government auditors and Medicare carriers use to score decisionmaking. Except for the determination of risk, the point system is used to score the complexity of medical records and test reviews and the number of diagnoses. Risk of complications and co-morbidities is determined by using a Table of Risk, which categorizes levels of risk as minimal, low, moderate and high. (See the Table of Risk chart on the insert.) Oncologists need score only four points or more to characterize those elements as high. Scoring four points or more in both categories warrants a high-complexity decision-making claim; or scoring at least four points in any one of the two elements along with proving high risk of complications also warrants a high-complexity medical decision-making claim.

Assuming a comprehensive history and comprehensive examination were performed and documented, highly complex medical decision-making justifies a level five E/M service, which includes 99205 (new patient E/M office or other outpatient visit) and 99215 (established patient office or other outpatient visit). Consultations, such as 99245 (new or established patient office consultation) can be billed with high complexity medical decision-making, assuming the physician meets the basic requirements for a consult.

Editors note: Detailed Questioning Key to Correctly Coding for E/M on page 13 of the February issue of Oncology Coding Alert discusses history taking;How to Meet the New E/M Exam Coding Requirements and Maximize Reimbursement on page 17 of the March issue discusses examinations.

Case Study: Cancer Patient

Consider the example of Patient A, who has a primary diagnosis of lung cancer and a recently diagnosed bone metastasis in the shoulder. The patient has been referred to Doctor Smith, a radiation oncologist. Here are items that will help determine the complexities of each of the three elements:

Diagnoses: lung cancer and bone metastasis
Management options: surgery, chemotherapy, radiation therapy

Complexity of medical records: request copies of the patient record, which is in the custody of referring physician in another state; record shows history of diabetes as well as primary cancer diagnoses and subsequent metastasis

Tests: magnetic resonance imaging (MRI), CT scan, bone scan

Information reviewed: reviewed most recent images, two CT scans

Risk of complications: complications include death from primary and secondary cancer diagnoses, as well as harmful side effects from radiation or chemotherapy

Explanation of risk and benefits: physician spent one hour with patient discussing treatment options

Counseling and coordination of care: additional time spent with family members regarding findings and to review prognosis and discuss treatment options.

Scoring Diagnoses

To score diagnoses, physicians have five problem categories to choose from, with each reported problem assigned one point. Each category is assigned a multiplier, one through four, which is factored in with the number of points in each category (that is, multiplier x points = score). The categories and their assigned multipliers are:

Self-limited or minor presenting problems 1
Established problem; stable or improved 1
Established problem; worsening 2
New problem, no additional workup planned 3
New problem, additional workup planned 4

In the case of Patient A, there is one established problem: lung cancer. Because the cancer is worsening, evidenced by the bone metastasis, the physician can use the established problem; worsening category with a two multiplier, which gives the physician two points.

(2 [established problem category] x 1 [reported problem] = 2)

The recently diagnosed bone metastasis constitutes a new problem in which an additional work up is planned, which gives the physician another four points and a running total of six points.

(4 [new problem, additional workup planned] x 1 [reported problem] = 4)

(4 + 2 = 6 running total)

Under this scoring method, the physician is justified in characterizing the number of diagnoses or management options as high because it exceeds the scoring threshold of four points.

Scoring Medical-records Data

The decision to obtain old records, discuss contradictory test results with the referring physician and independent review of medical records plays a role in determining the complexity of medical decision-making. Obtaining and reviewing old records or history from sources other than the patient increases the amount and complexity of reviewed data, Parman says. In the scoring system that Parman advocates, the following data review items are used to determine complexity of medical records by adding the number of assigned points:

review and/or order clinical laboratory tests 1 point

review and/or order radiology tests 1 point

review and/or order tests from the Medicine Section of CPT 1 point

discussion of diagnostic tests results with performing physician 1 point

independent review of an image, tracing or specimen that previously has been interpreted by another physician 2 points

decision to obtain old records and/or obtain history from someone other than the patient 1 point

review and summarize old records and/or obtain history from someone other than the patient 2 points

Still working with Patient A, the physician performed the following services:

ordered and reviewed radiology test 1 point

independent review of two images, at two points each 4 points

obtaining old records 1 point

Total score 6 points

Weighing Risk

The third element is risk of complications. Determining the difference between minimal-risk level and high-risk level requires an assessment of presenting problems, diagnostic procedures ordered and chosen management options. For oncology physicians and oncology sub-specialists, most cases will fall either in the moderate to high categories. But to ensure you are choosing the appropriate risk level, Parman offers a matrix. Physicians only need to prove a high-risk level either in presenting problems, diagnostic procedures ordered or management options selected to characterize risk as being high.

In the clinical example being used, the patients risk level is high in two of the three categoriespresenting problems and management optionsbecause the presenting problems pose a threat to life and management options include surgery and drug therapy that requires intensive monitoring for toxicity.

The radiation oncologist who would be billing for an E/M service in this example safely can characterize his or her medical decision-making in this case as highly complex, with an objective scoring system to support the claim. Overall, the physician scored high in both the diagnoses and data review categories, and high in the risk category, fulfilling more than the required two elements.

At first, physicians resist using a scoring system, Parman says. Assigning points to a variety of tasks seems too complicated or too time consuming to implement. But Parman reminds physicians how time consuming and painful an audit can be.

Its not too much trouble once you get used to it, Parman says. Eventually it will not take them any longer than it takes now.