Wiki How to Count Hx of cancer in Problems for MDM

[lgardner]

Hello fellow coders-

I have an encounter where an established patient came in with a complaint of blood in urine and rectal bleeding (which had stopped 2 days ago).
Patient has a history of prostate cancer and in her A/P for the hematuria, she states that it "may be secondary to prostate, recommend f/u with urology".

3 tests were ordered and 2 tests reviewed (from recent hospital visit).
The only treatment plan was the referral to urology.

How would you consider the hx of prostate cancer?
Would you consider this a 99213 or a 99214?

I am a bit on the fence.
I am running an educational audit on this provider. She submitted a 99213, which I don't necessarily disagree with, but I feel that if her documentation was a bit more specific (especially about her thought that this may be related to the hx of cancer), this could have been a 99214.
I am struggling with the title question.

thanks!

 

[csperoni]

I would likely consider this 99214. For blood in urine and rectal bleeding with a history of prostate cancer, I would call the problem moderate, not low.
Something like "referral to urology to r/o cancer recurrence" or "hematuria concerning in light of prostate cancer history" or "rectal bleed concerning with patient's history of radiation treatment". Odds are, those are items the clinician thought about, but did not necessarily put onto the page. I have tried to stress to my clinicians with MDM being the only element now, it is more important than ever to have your thought process clear in the note.
Even without a statement like I suggested above, in an audit, I could certainly make a case for "undiagnosed new problem with uncertain prognosis" with those symptoms and history.
If it were a very remote history of a stage 1A cancer and lacking a provider statement relating them, I could lean toward 99213. But with the information provided, this is most likely 99214.

 

[lgardner]

I would likely consider this 99214. For blood in urine and rectal bleeding with a history of prostate cancer, I would call the problem moderate, not low.
Something like "referral to urology to r/o cancer recurrence" or "hematuria concerning in light of prostate cancer history" or "rectal bleed concerning with patient's history of radiation treatment". Odds are, those are items the clinician thought about, but did not necessarily put onto the page. I have tried to stress to my clinicians with MDM being the only element now, it is more important than ever to have your thought process clear in the note.
Even without a statement like I suggested above, in an audit, I could certainly make a case for "undiagnosed new problem with uncertain prognosis" with those symptoms and history.
If it were a very remote history of a stage 1A cancer and lacking a provider statement relating them, I could lean toward 99213. But with the information provided, this is most likely 99214.

This was, exactly what I was thinking.

Luckily, this is an "audit" requested by the provider, so she is very engaged. She had asked me to check on how she is leveling her E/Ms, so I want to provide her examples of how small changes in her documentation, can support a higher LOS.

Thank you, Christine!
I really appreciate your thoughts on this.