Oncology & Hematology Coding Alert

Question: We are treating a patient with chronic lymphocytic leukemia (CLL). The condition is not worsening but is not responding to treatment. Is this counted as a stable chronic illness in terms of the number and complexity of problems element of medical decision making (MDM) per the CPT^® guidelines for office/outpatient evaluation and management (E/M) services? If so, does this only rise to a low level in this element of MDM? Or is there a way to document it at a higher level?

Wisconsin Subscriber

Answer: According to the CPT^®’s definitions for the office/outpatient E/M services elements of MDM, a stable chronic illness “is defined by the specific treatment goals for an individual patient.” The definition also goes on to note that chronic conditions are also not stable “if the condition has not changed and there is no short-term threat to life or function” or “if the patient is asymptomatic [and] the risk of morbidity without treatment is significant.”

In other words, your patient cannot be regarded as stable even if they have a chronic illness that is not worsening. The condition must be placed in the chronic illness with exacerbation, progression, or side effects of treatment category of the number and complexity of problems element of MDM (the moderate level of that element) or the chronic illness that poses a threat to life or bodily function in the near term without treatment (the high level of the MDM element). If either case is true, you should then determine the exact MDM level for the CLL using the following criteria:

• Moderate: Under CPT^® definitions, these are chronic conditions “requiring additional supportive care or requiring attention to treatment for side effects.” They are also conditions that are being treated “with an intent to control progression.”
• High: Under CPT^® definitions, these are chronic conditions that have “severe side effects of treatment” and that “have significant risk of morbidity and may require escalation in level of care.” The definition also includes conditions where symptoms pose “a potential threat to life or bodily function,” and where “the evaluation and treatment are consistent with this degree of potential severity.”

So, as your patient’s CLL meets one of these definitions, and providing one of the other two MDM elements in the encounter also rises to the moderate or high level, you can go ahead and code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making …) or even 99215 (… high level of medical decision making …) for this patient encounter.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC