Don’t Automatically Assign a High E/M COPA Level for Cancer Dx
Question: A patient with stage IV colon cancer presents for a follow-up, and the provider discusses surgery to remove the tumor and the risks that would involve. Would you consider the complexity of problems addressed (COPA) in an evaluation and management (E/M) level calculation as high for an acute or chronic condition that poses a threat to life or bodily function? We had an independent auditor review, and they are saying this only supports a chronic condition with exacerbation, which would mean we should assign a moderate level of E/M for the COPA element of medical decision making (MDM). AAPC Forum Participant Answer: You cannot presume a blanket level of COPA based on a cancer diagnosis, no matter what the severity of the condition. In its definitions, the AMA says acute or chronic illnesses are conditions that pose a “threat to life or bodily function in the near term without treatment.” However, they do not go on to say what, exactly, “in the near term” means. The AMA also defines chronic illnesses with severe exacerbation, progression, or side effects of treatment by saying they are conditions “that have significant risk of morbidity and may require escalation in level of care,” again without specifying what the significant risk is, or what an escalation of care looks like. This means automatically assigning a level of COPA isn’t always possible with a condition like stage IV colon cancer, which can technically refer to both a patient with a large but excisable solid tumor and a patient with an unresectable tumor causing bowel obstruction with growth into nearby genitourinary (GU) organs and peritoneal carcinomatosis. In both situations, the timeframe of the threat to bodily function, the risk of morbidity, and the level of care are very different. So, to reach a high level of COPA, the provider’s note must clearly state that the patient’s condition requires urgent intervention to prevent loss of life or function. Check out this resource: The American Society of Clinical Oncology (ASCO) has some good examples of what presenting problems support a high level of COPA in its “Medical Decision Making Simplified” document. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
