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 [...]