Est pt visit: pt on chemo - mdm?

[andersee]

Pt is on chemo for cancer. We place the risk as High (drugs intensive monitoring). In terms of the diagnosis box, how should this be coded?

1. 2 established problems, worsening/not controlled (chemo, cancer) = 4 pts
2. 1 established problem, worsening/not controlled (cancer) + any symptoms or other issues documented = 2 or more pts depending on documentation

The real question is if chemo is considered a "problem" in and of itself or would only the symptoms of the side effects, if any, be counted under the diagnosis box.

Please, everyone, weigh in with your opinions and/or any resources you have to help us clear up how to code these services.

Thanks much!!!

 

[FTessaBartels]

Depends on documentation

It depends on the documentation - of course.

Your main complaint is the cancer ... and it is NOT worsening unless the physician specifically states that it is. It is stable or improved.

Chemo is not a complaint, any more than any other medication/treatment is a complaint. However, side effects of the treatment may be a complaint. So if the patient is complaining of nausea, night sweats, dizziness, etc those may be considered separate problems (if they are actually being addressed, and not just listed).

And any one of these side effects may be a "new" problem if it's the first time the patient is complaining of them.

It all depends on the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[andersee]

That is my feeling too but this is not shared by everyone. Do you have any resources or documentation that support what we think? I have not found any - or anything to contradict it either.

Thanks!