Wiki level for malignancy with NED?

[wynonna]

Hello:

Patient has malignancy treated successfully. T1N0 squamous cell carcinoma of right true vocal cord treated with radiation therapy completed April 16, 2021.
Our MD notes: "No evidence of recurrent disease"
He does a detailed/comprehensive exam most likely to rule out any other potential malignancies.
For an established patient, would this be considered a 99212 OR 99213?
thank you

 

[csperoni]

This is not enough information to determine MDM, which is based on the problem, data and risk.
Problem seems like 1 chronic stable, so that is low (level 3).
If you assume there are no tests order/reviewed, no independent historian, no discussion with external QHP, then data is none (level 2). If any of those items were done, you could have limited (level 3), moderate (level 4), or extensive (level 5).
Depending on the patient management, risk could be minimal (level 2), low (level 3), moderate (level 4), or high (level 5).
Your final code could be 99212, 99213, 99214 or 99215 depending on the 2 other elements of MDM.
The exam does not count for leveling E/M since the guideline change 01/01/2021.

 

[wynonna]

Thank you for your input. Wouldn't cancer by its very nature carry a low risk "of complications and or morbidity or mortality in diagnostic testing or treatment" (3rd column in MDM)
Meaning a level 3? (low risk in chronic illness and low risk under "Risk of complications as above"?
thanks

 

[csperoni]

Not necessarily. A cancer that has already been successfully treated and is no evidence of disease is usually coded as a "history of" malignancy, not an active malignancy. You might monitor the patient for several years. Although the AMA did not give specific examples on their low risk table for the 2021 changes, most other organizations that I have seen use the previous low risk examples.
OTC meds; PT, OT, non cardio imaging studies with contrast; IV fluids; decision for minor surgery without identified risk factors, needle biopsy, etc.
If the patient is not receiving any further treatment, and the cancer has been removed, with no mets and low staging, not ordering any testing, you need something to justify low risk. Only the fact that there is a history of cancer does not inherently make it low risk.

 

[wynonna]

thank you!