Wiki Moderate or High level with cancer talk

Create Wiki
C

Ckrogers

Contributor
Messages
13
Location
Milwaukee, WI
Best answers
0
Hello,

This has been an ongoing discussion in my office and we cannot settle on an answer, I would like your opinions. In this case the patient has had a prostate biopsy performed by our providers. When the biopsy results confirm cancer, a patient is brought in to discuss the results. The cancer would fall into high complexity, no new data is reviewed except our biopsy results so that is straightforward. Our issue then is the risk management and we have been unsure of Moderate vs. High. The doctor gives many options for medication, and surgery with risk at a moderate level. The main problem is a referral for radiation oncology. Does this referral qualify as drug therapy requiring intensive monitoring of toxicity, making it High level patient management? Please help us settle this debate.

Thanks
 
Ckrogers said:
Hello,

This has been an ongoing discussion in my office and we cannot settle on an answer, I would like your opinions. In this case the patient has had a prostate biopsy performed by our providers. When the biopsy results confirm cancer, a patient is brought in to discuss the results. The cancer would fall into high complexity, no new data is reviewed except our biopsy results so that is straightforward. Our issue then is the risk management and we have been unsure of Moderate vs. High. The doctor gives many options for medication, and surgery with risk at a moderate level. The main problem is a referral for radiation oncology. Does this referral qualify as drug therapy requiring intensive monitoring of toxicity, making it High level patient management? Please help us settle this debate.

Thanks
Click to expand...

I would not consider a referral for radiation oncology to qualify as drug therapy requiring intensive monitoring of toxicity.

Radiation therapy is not drug therapy.

(If the patient eventually begins radiation treatment, they will be monitored for radiation toxicity. However, the radiation oncologist is doing that monitoring, not the urologist.)
 
Thank you for the previous answer. I'd like to expand this question if I could.
Doctor A, diagnoses prostate cancer and creates a plan for the patient to see practice partner, Doctor B, to discuss robotic prostatectomy (Doctor A does not do this surgery) and enters paragraph:
 "We extensively discussed prostate cancer. Prostate cancer unfortunately being a very deadly disease however quite variable from individual to individual. Many factors we evaluate in tailoring the treatment to fit the patient are patient's age, health, views on treatment and desires, PSA, PSA trend and doubling time, amount of disease within the biopsy specimen and aggressiveness of the prostate cancer in the pathologic specimen. Pending the evaluation of all these factors, then we determine whether observation, surveillance, various forms of surgical intervention, various forms of radiation or cryoablation or other treatment options may deem appropriate. We extensively discussed hormone blockade, and how testosterone and other androgens impact various forms of prostate cancer, and how this hormone blockade can be accomplished to various methods. We extensively discussed the various observation and surveillance protocols. Depending on the patient's prostate cancer and overall variables, and general surgical intervention is warranted in individuals whom are healthy, good surgical candidates and her on the younger spectrum of patients with prostate cancer. In individuals who are on the older spectrum, or more complex medical history however still candidates for treatment forms of radiation are generally recommended. However there are side effects second occur with any treatment. In general these include incontinence, erectile dysfunction, urethral stricture disease, injury to the bladder or surrounding organs structure or the rectum. We discussed multiple complications that have occurred with surgical, radiation and cryoablation treatment options. We also extensively discussed the various treatment options for surveillance or observation. We discussed how we treat prostate cancer by a coordinated effort with the cancer care coordinator, radiation oncology and urology, and rarely other specialists in determining what is best for the individual. Depending on the extent of his prostate cancer, many times creating a baseline of the extent of the cancer is warranted with either a MRI, bone scan or CAT scan. The Patient demonstrated understanding of the diagnosis, treatment options, goals of treatment as well as risks and potential side effects with radiation therapy. He has asked several pertinent questions, which demonstrate an accurate understanding of the above points. He would like to consider his options further."
Doctor A does not document time spent. Is requesting a 99215 based on the risk of surgery. Is the documentation above enough to allow for 99215, or does there need to be more specifics regarding the surgery recommended and the condition of the patient? My concern is that the paragraph is too generalized, and the decision to do surgery has not been made yet.
Will Doctor B also be able to request a 99215 if he discusses the specific surgery and the risks it entails?
 
Ckrogers said:
Thank you for the previous answer. I'd like to expand this question if I could.
Doctor A, diagnoses prostate cancer and creates a plan for the patient to see practice partner, Doctor B, to discuss robotic prostatectomy (Doctor A does not do this surgery) and enters paragraph:
"We extensively discussed prostate cancer. Prostate cancer unfortunately being a very deadly disease however quite variable from individual to individual. Many factors we evaluate in tailoring the treatment to fit the patient are patient's age, health, views on treatment and desires, PSA, PSA trend and doubling time, amount of disease within the biopsy specimen and aggressiveness of the prostate cancer in the pathologic specimen. Pending the evaluation of all these factors, then we determine whether observation, surveillance, various forms of surgical intervention, various forms of radiation or cryoablation or other treatment options may deem appropriate. We extensively discussed hormone blockade, and how testosterone and other androgens impact various forms of prostate cancer, and how this hormone blockade can be accomplished to various methods. We extensively discussed the various observation and surveillance protocols. Depending on the patient's prostate cancer and overall variables, and general surgical intervention is warranted in individuals whom are healthy, good surgical candidates and her on the younger spectrum of patients with prostate cancer. In individuals who are on the older spectrum, or more complex medical history however still candidates for treatment forms of radiation are generally recommended. However there are side effects second occur with any treatment. In general these include incontinence, erectile dysfunction, urethral stricture disease, injury to the bladder or surrounding organs structure or the rectum. We discussed multiple complications that have occurred with surgical, radiation and cryoablation treatment options. We also extensively discussed the various treatment options for surveillance or observation. We discussed how we treat prostate cancer by a coordinated effort with the cancer care coordinator, radiation oncology and urology, and rarely other specialists in determining what is best for the individual. Depending on the extent of his prostate cancer, many times creating a baseline of the extent of the cancer is warranted with either a MRI, bone scan or CAT scan. The Patient demonstrated understanding of the diagnosis, treatment options, goals of treatment as well as risks and potential side effects with radiation therapy. He has asked several pertinent questions, which demonstrate an accurate understanding of the above points. He would like to consider his options further."
Doctor A does not document time spent. Is requesting a 99215 based on the risk of surgery. Is the documentation above enough to allow for 99215, or does there need to be more specifics regarding the surgery recommended and the condition of the patient? My concern is that the paragraph is too generalized, and the decision to do surgery has not been made yet.
Will Doctor B also be able to request a 99215 if he discusses the specific surgery and the risks it entails?
Click to expand...

I agree with you that the paragraph sounds very generalized. Lots of words about prostate cancer in general. Not many words that are specific to this patient.

To be fair, I'm not a clinician. I read a lot of E/M notes written by oncologists, but I myself am not a clinician.

The paragraph covers how prostate cancer affects old people, young people, and people with complex medical histories but doesn't even state which category this patient falls into!

(My dad is being treated for prostate cancer right now. If I read this paragraph in his chart, I'd wonder why his visit note spent time talking about the effects on young people. My dad is in his 80s - tell me more about the risks to him and less about what the risks to a hypothetical young person would be.)

Doctor B's note would stand alone, so as long as that note substantiates a Level 5 visit Doctor B should be fine.

I'm only seeing a paragraph from Doctor A's note and not the whole thing, so I'm hesitant to say that it doesn't qualify for a Level 5. Clearly, they had a lengthy visit with the patient - it's unfortunate that they didn't document the time spent.
 
I'm on the same page as @sls314 here. Stating risks/treatments that don't even apply to this patient are not relevant and should not be part of leveling the visit. If the problem is high (level 5), data is anything less than extensive (level 4 or below), I would consider this paragraph as average risk (level 4), resulting in an overall 99214. I do believe the provider MAY have actually provided a level 5 visit, but did not document well enough to code that. This is likely a macro or template used for all patients. While I don't have an issue with macros, the addition of one or two sentences that are about what the unique decision or recommendation is for THIS patient could make all the difference for a level 5 risk. Opportunity for education!!
 
You must log in or register to reply here.
Top