Wiki Risk of Complication and/or Morbidity or Mortality

[leastratton1001]

I am hoping for some input/clarification of a few things that I have learned. I am newer to E/M coding so trying to ensure my understanding. When it comes to High Risk for the following aspects- I took a recent education that to get into a high category for presenting problem with the below options- the patient would basically would require hospitalization or the condition needs to pose a threat to life or bodily function in the near term (imminent) not just a patient who has cancer who has a diagnosis of 6 months or less. Hoping for some insight as this is for Palliative Care CPT coding.

One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
Acute or chronic illnesses or injuries that may pose a threat to life or bodily function,e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

 

[csperoni]

Be careful about confusing the complexity of problem with the risk of MANAGEMENT. The risk is not of the problem itself, but rather the risk of the treatment or management. While they often correlate, that is not always the case.
From the AMA guide:
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.

For problem - to get to high, you have one the situations listed. In general, a cancer patient with < 6 months has a chronic illness with severe exacerbation or progression AND an acute or chronic illness that poses a threat to life or bodily function in the near term. I have not seen any definition of "near term." But terminal cancer with < 6 month prognosis will likely have a treat to at least bodily function if not life in the near term. Additionally, they likely have mets - possibly to multiple sites. I would certainly consider that severe progression.
A patient with a newly diagnosed, low grade, slow growing cancer will usually not meet high level for problem.

The decision regarding hospitalization falls under risk of management as high.

So to get to overall high level 5 on MDM, then your statement about "patient would basically require hospitalization" makes more sense. But you may frequently have a high level problem, but moderate data and risk of management, so an overall moderate.

PS - In my experience, palliative care is one of few specialties where coding based on time often works in their favor. They tend to spend a lot of time with the patient, discussions with family, discussions with other clinicians for coordination of care, thoroughly reviewing records, etc. An outpatient follow up the provider might spend 40+ minutes or inpatient 50+ minutes, but is not high overall MDM.

I hope this clarifies some of it for you.

 

[Queizati]

Hello, I have recently begun coding for palliative visits as well and reading through this discussion was wondering if for number and complexity of problems addressed we can factor in the patient’s cancer diagnosis even though palliative care physicians provide symptom management from the disease and side effects of treatment and aren’t treating the cancer itself?

 

[csperoni]

Hello, I have recently begun coding for palliative visits as well and reading through this discussion was wondering if for number and complexity of problems addressed we can factor in the patient’s cancer diagnosis even though palliative care physicians provide symptom management from the disease and side effects of treatment and aren’t treating the cancer itself?

Yes, I would absolutely factor in the cancer diagnosis. Palliative care is addressing the cancer. Most/many of the symptoms they are managing are due to the cancer, or the side effects of the cancer treatment.

 

[Queizati]

Yes, I would absolutely factor in the cancer diagnosis. Palliative care is addressing the cancer. Most/many of the symptoms they are managing are due to the cancer, or the side effects of the cancer treatment.

Thank you for your input, it's most appreciated. I want to be sure we are giving credit where credit is due for encounter complexities.