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E/M Level with malignancy

S

sewilke

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West jefferson, NC
If a patient with, for example, stage IV colon cancer or pancreatic cancer, is presenting for a follow-up and discussion takes place of surgery to remove the tumor with risks discussed, would you consider the complexity of problems addressed as HIGH for an acute or chronic condition that poses a threat to life or bodily function? We had an independent auditor review, who is saying these only support a chronic condition with exacerbation. I would love to get opinions from coders/auditors with experience in hematology/oncology please!
 
Unfortunately, a blanket level of COPA can not be presumed just based on a cancer diagnosis. Remember that the additional information from the AMA states,

Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.

Although there is no further clarification on what exactly "in the near term" means, it should be clear from the provider's note that the patient's condition requires urgent intervention to prevent loss of life or function.

Also, remember that Stage IV colon cancer can technically mean both a patient with a large but excisable solid tumor with newly discovered bone metastasis and a patient with an unresectable tumor causing bowel obstruction, with growth into nearby GU organs, and peritoneal carcinomatosis.

ASCO has some good examples of what presenting problems support HIGH COPA, check out their 'MDM Simplified' tips here: https://www.asco.org/practice-patients/billing-coding-reporting/coding-reimbursement
 
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