Monitoring of Past Cancer - Level of MDM?

[mawashington]

Hello,

If a patient is being monitored for recurrence of a past cancer and no evidence of recurrence is documented, how are you treating this in terms of medical decision making?

 

[csperoni]

MDM has 3 components, currently:

• # of diagnoses
• data
• risk

The past cancer would currently be an established problem (either stable, improving, or worsening depending on patient's state). There may be additional diagnoses being treated, and you could count those as well.
Data - did you review or order labs, radiology, etc?
Risk - if currently NOD and no complaints, I would call that a stable chronic illness (level 3)
- if currently NOD and perhaps a mild complaint, I would call that a chronic illness with side effects (level 4)
- if currently experiencing signs of recurrence, I would call that a chronic illness that poses a threat to life or bodily function (level 5)
So, depending on other diagnoses, what is ordered/reviewed and the status of the patient, you could be level 2, 3, 4 or 5.

2021 rules will differ.

 

[mawashington]

MDM has 3 components, currently:

• # of diagnoses
• data
• risk

The past cancer would currently be an established problem (either stable, improving, or worsening depending on patient's state). There may be additional diagnoses being treated, and you could count those as well.
Data - did you review or order labs, radiology, etc?
Risk - if currently NOD and no complaints, I would call that a stable chronic illness (level 3)
- if currently NOD and perhaps a mild complaint, I would call that a chronic illness with side effects (level 4)
- if currently experiencing signs of recurrence, I would call that a chronic illness that poses a threat to life or bodily function (level 5)
So, depending on other diagnoses, what is ordered/reviewed and the status of the patient, you could be level 2, 3, 4 or 5.

2021 rules will differ.

Thank you, this is very helpful.

Would you classify the monitoring of a past cancer as a chronic illness in 2021, or would you consider this to be a minor problem, assuming no recurrent cancer is documented?

 

[SharonCollachi]

Thank you, this is very helpful.

Would you classify the monitoring of a past cancer as a chronic illness in 2021, or would you consider this to be a minor problem, assuming no recurrent cancer is documented?

I am not sure that you can ever classify a past cancer as a "minor" problem.

 

[kbrooks4428]

If the patient presents as a new patient to your practice but has history of a past cancer, do you mark as chronic illness in MDM or can you count as a new diagnosis since they are a new patient to your practice?

 

[csperoni]

If the patient presents as a new patient to your practice but has history of a past cancer, do you mark as chronic illness in MDM or can you count as a new diagnosis since they are a new patient to your practice?

I would count this differently depending on the exact circumstances (ie How past is past? Are you the physician monitoring the cancer for signs of recurrence? Or is it really just an element in their history?)
Two different extreme examples:
1) You are a PCP. New patient comes to you and in taking her history, she states she had ovarian cancer 25 years ago treated with surgery, no further treatment needed and no further problems. You advised her to ensure she sees her gyn annually. I would certainly not count that a new diagnosis.
2) You are a gynonc. New patient comes to you and had surgery for stage 4 ovarian cancer 8 months ago, followed by paclitaxel/carbo chemotherapy; BRCA II+. Post treatment PET shows NED. That I would certainly call a new problem.

Additionally, the way you worded your question is a bit confusing to me. For 2020, whether the illness is chronic or acute falls into the risk table of MDM. Whether it is a new problem or established problem falls in the issue being treated element of MDM. For 2021 office visits, new problem or established problem no longer matters.

PLEASE NOTE: New problem to the examiner applies across groups of the same specialty, similar to new patient definitions. So if in example 2 above, the original surgeon was another gynonc part of the same very large (2400+) health system group of physicians, this would be an established patient with an established problem. https://www.aapc.com/blog/48792-mdm-new-problem-to-examiner-or-patient/

 

[rachaelwilleford]

I've been counting as a chronic illness. It's something that as an oncologist you'll always keep as a consideration when there's an issue that pops up.