Oncology & Hematology Coding Alert

Clinician judgement and thought process are key to assigning and supporting higher levels of patient management.

The reader question “Raise Your MDM Risk Level High on These Toxic Agents” that appears elsewhere in this issue of Oncology & Hematology Coding Alert prompted us to look at other questions you had regarding the Risk of Complications and/or Morbidity or Mortality of Patient Management element of medical decision making (MDM).

Here are some of the most frequent you’ve asked about determining risk levels in MDM calculations. We’ve also included answers and expert opinions you can apply to your decision making.

Question: When we talk about risk in terms of MDM, what do we really mean?

Answer: In the 2022 AMA CPT^® code book, the 2021 evaluation and management (E/M) Services Guidelines provide several definitions that you should apply when determining the risk level of an office/outpatient E/M service:

• Risk is “based upon the usual behavior and thought processes of a physician or other qualified health care professional.”
• Risk is “based upon consequences of the problem(s) addressed at the encounter when appropriately treated.”
• Risk “includes MDM related to the need to initiate or forgo further testing, treatment and/or hospitalization.”

In other words, risk is determined not by the specific treatment the provider recommends, but by the thought process the provider undergoes to arrive at the decision whether or not to treat the patient and by the positive or negative effect a particular treatment may have on a patient’s condition. So, a treatment or surgery considered for a patient could count as a moderate or high risk element for MDM whether or not the provider or the patient decided to follow through with it.

Question: How do I determine what level of risk surgeries are?

Answer: CPT^® tells you that minor or major surgeries “are not defined by a surgical package classification,” so you cannot use global package information to determine risk for a particular procedure. Instead, as with any risk determination, the provider is the one who should make the eventual determination based on “risk factors … relevant to the patient and the procedure,” per CPT^® guidelines. Again, this level is not dependent on the surgery actually being performed; if a provider recommends surgery and the patient decides against it or wants to put it off or get a second opinion, the risk level remains the same as it would if the surgery went ahead as planned. It is also important to note that both elective and emergent procedures can be classified as either minor or major. The terms simply describe the timing of a procedure as it relates to the patient’s condition.

Question: Can over-the-counter (OTC) medication drug management ever rise to the moderate risk level?

Answer: An OTC medication probably presents a low-risk MDM element, but under the right circumstance, it could rise to a moderate level. For example, OTC antacids can make tyrosine kinase inhibitors (TKIs) — drugs that are widely used in treating chronic myloid leukemia (CML) — less effective, while antifungals can make TKI levels increase to an unsafe level. If a provider factors the risks of using such OTC medications for a CML patient receiving TKI therapy into their MDM, then you can make a case for the risk element to rise to moderate for the encounter. However, the provider must document how these OTC medications may impact other ongoing therapy. If this is not documented, it may be missed upon coding/audit or questioned by the payer.

But remember: You should “ask, ‘do you need that information in order to support a higher level?’ Because you can use two out of the three MDM elements, I wouldn’t spend time counting it unless it was going to mean the difference between one level and another that was medically necessary. I see if the level resonates with the service rendered,” suggests Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC and member of the CPT^® Editorial Panel.

Question: At the moderate risk level, what does CPT^® mean by the example of a “diagnosis or treatment significantly limited by social determinants of health (SDoH)?”

Answer: SDoH are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” They include such things as the “availability of resources to meet daily needs (e.g., safe housing and local food markets) … access to educational, economic, and job opportunities … access to health care services, quality of education … transportation options … social support … socioeconomic conditions … [and] language/literacy,” according to the Office of Disease Prevention and Health Promotion (ODPHP) (https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health).

When your provider notes that one or more of these things “significantly limits” a patient’s diagnosis or treatment (for example, a patient’s economic circumstances inhibit their ability to pay for a drug treatment, or their lack of transportation affects their ability to attend appointments), then you can use the information to assign a moderate risk level of MDM of morbidity to the encounter.

Documentation alert: In addition to notations in the medical record, codes from Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) “can be part of documenting circumstances in the patient’s life that support a moderate level of risk when those circumstances significantly limit diagnosis or treatment,” advises Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

“Code assignment,” in such cases, “may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider” as well as “patient self-reported documentation … as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider,” per ICD-10-CM Guidelines I.B.14 and I.C.21.c.17.

Graze on the Guidelines Before Heading to the Table

In short, when trying to calculate the level of MDM for a particular encounter, don’t make the mistake of simply using the MDM table to assign an office/outpatient E/M code. There are other tools at your disposal to help make this part of your job easier. “Many people go right to the MDM grid and miss all the important information in the guidelines, including the definitions, that precede it,” Jimenez noted.