Identified Risk Factors in High Medical Decision Making for a Potential Malignancy

Bridgton, ME
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There is a debate between the doctors and our department:

An ultrasound was done and the patient has a 5 cm mass near her ovary. The MD is planning surgery to remove the mass, it is not known for certain whether or not the mass is benign or malignant. The MD believes that the mass is an identified risk factor because the mass is potentially cancerous. We believe that at this point, the surgery should not be given credit for high risk surgery with identified risk factors because the mass is not identified as being cancerous at this point.

I could consider this being a risk factor if the provider makes the case for it in the note, but just a mass with the potential of being malignant we do not believe to be an inherent identified risk factor.

Thoughts???? Thank you!


True Blue
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I agree with you - the note needs to reflect the provider's assessment of the level of the risk to the patient and support that they are managing a condition that poses an imminent threat. Per the official guidelines: "Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented....The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment." The fact that a condition could potentially turn out to be high risk at some point in the future does not, in and of itself, mean that the provider is managing a high risk situation at the current encounter.

I'd add that even if it was a malignancy, not all malignancies are necessarily high risk. I encountered a similar situation in one of my practices a while back - an encounter that had been coded at the highest level due to a diagnosis of cancer of the cecum was selected for audit by the Medicare contractor and was down-coded. The practice auditor appealed the determination citing the diagnosis as one that was high risk because it posed a threat to the patient's life. The appeal was denied and the original determination upheld because the physician's notes did not reflect that level of risk to the patient, and the contractor determined that the diagnosis alone was not sufficient.