Wiki CC for Oncology

[cpccoder2008]

How would an Oncologist word the CC for cancer patients to reach 4 HPI elements ?? He is just stating what type of cancer the patient has like "High risk colon cancer" or "Lung Cancer"

 

[LLovett]

Confused, chief complaint and HPI are not the same thing. You can pull a chief complaint from the HPI but you don't have to.

So you could have a chief complaint "Recheck colon cancer"

Then HPI of "colon cancer, found during routine c-scope 6 months ago, currently undergoing chemo, pt denies N/V/D"

This is just me making something up off the top of my head but you would have location, context, duration, mod factors, and associated S&S.

Hope this is helpful,

Laura, CPC, CEMC

 

[cpccoder2008]

He is wording the CC and HPI as the same statement. All he is writing is Recheck of cancer or f/u for cancer then completing his PE and ROS.

 

[FTessaBartels]

Established patient

For an established patient visit you need to meet two of the three key elements:
History
Exam
Medical decision Making

You say the physician has a chief complaint (F/U for cancer), a PE and an ROS.

Where is the plan of treatment? Where is the assessment of the problem ... is the cancer responding to treatment? Getting worse? Stable? Are there labs or xrays ordered or reviewed?

If you truly only have a CC, PE and ROS ... you have a level 1 established patient visit (which really requires nothing more than a complaint).

I think you physician needs some education. Adequately documenting a 99213 established patient visit shouldn't be too onerous.

Using Laura's example: So you could have a chief complaint "Recheck colon cancer" Then HPI of "colon cancer, found during routine c-scope 6 months ago, currently undergoing chemo, pt denies N/V/D" I would count CC. HPI of location (colon), context (found on routine c-scope), duration (6 months), mod factor (undergoing chemo). AND a prob pert ROS (GI for no N/V/D). This gives you an EPF history.

So you'd need EITHER an EPF exam -or- Low level MDM, and that would give you a 99213.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Karolina]

Hi - I do quite a bit of oncology E&M and usually there is a bit more than just the name of the Ca, e.g., lung Ca. "Lung" would definitely support the location. Usually there is a mention of tx, e.g., chemo with ______ (drug), which would provide the modifying factor/s. Sometimes they say it's a stage IV - which gives us severity and perhaps that the patient is receiving cycle 6, day 1 which does give some sense of duration. Most of the time I find more than 4 HPI elelments. An opening line like "Patient here for follow up of stage IV lung ca. diagnosed in Jan 2009 on chemo with ________ (drug)" satisfies 4 HPI elements. Sometimes it is clear like this, at other times there is a bit of seek-and-find involved.

 

[cpccoder2008]

Hi - I do quite a bit of oncology E&M and usually there is a bit more than just the name of the Ca, e.g., lung Ca. "Lung" would definitely support the location. Usually there is a mention of tx, e.g., chemo with ______ (drug), which would provide the modifying factor/s. Sometimes they say it's a stage IV - which gives us severity and perhaps that the patient is receiving cycle 6, day 1 which does give some sense of duration. Most of the time I find more than 4 HPI elelments. An opening line like "Patient here for follow up of stage IV lung ca. diagnosed in Jan 2009 on chemo with ________ (drug)" satisfies 4 HPI elements. Sometimes it is clear like this, at other times there is a bit of seek-and-find involved.

Thank you,, i spoke with him earlier and gave him a simular example. He is doing a comp exam and history, but not meeting the 4 HPI's. I showed him the correct way to do it and i think he understands better now. He wasn't being specific enough, he was just writing lung cancer. This is a new service for me and we are just starting to learn. I am trying to find all the help i can get so if anyone does oncology billing i would REALLY appreciate the help... !!!