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MDM for Oncology

  1. #1
    Default MDM for Oncology
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    Our group just recently took on our first Oncologist. I do quarterly documentation reviews for all physicians within our group, and just met with the Oncologist to go over his documentation. Can someone please help me, and the physician, understand Oncology in the Medical Complexity world when reviewing documentation in the Medical Decision Making part?

    Obviously Oncology is a very unique and serious specialty, but when determining the complexity of the problem, how is it NOT going to be high complexity? The physician states that a lot of his patients are going to be high complexity because they have a serious illness that may pose threat to the patient's life. I don't disagree with that, but there are a lot of illnesses out there that may pose threat to the patient's life. I try to educate my physicians by saying, "What was the status of the patient on this particular encounter? If this patient was not in the current deteriation state, then I would probably not code based on a high complexity."

    Can someone please guide the Oncologist and myself in the right direction when determining the Medical Decision Making for this specialty.

    I would apprepriate any direction!!
    Tiffany Fischer, CPC, CEMC

  2. #2
    I code for an Oncology/Hematology clinic with 6 MD's. No E/M, just dx and procedure coding. All of our patients are obviously complex, however many things need to be considered when deciding just how complex. For instance a 45 yr old otherwise healthy female with 174.9, V86.0 currently in her 3rd year of Tamoxifen V07.51 is fairly straight forward with bi-annual CBC's and Ca 125. Then a 82 year old female with 174.9, v86.0, 285.22, 285.21, 585.3, 288.03, 287.49, e933.1, 428.0, 250.00, v58.67, 783.21, 268.9, and 427.31, V58.61.......see what I mean? I won't even get started on the Chemo drugs she is on, her adverse effects to them, the meds she takes to counter act those effects, in addition to her regular meds for her co-morbidities.
    Neoplasm by itself is a complex disease with some serious MDM skills required, but sometimes it can be straight forward, and sometimes very chaotic, not to mention the fine line that often runs down the middle!

    Lisa Bates
    Last edited by Lisarae1970; 12-02-2010 at 11:34 AM.

  3. #3
    Greensboro, NC
    I am working with a single hematology/oncology physician, and she needs a lot of help with her documentation. She is using paper charts, and I have given her maybe 8 or more problem visit examples to help her with her documentation, but we have not found one that she likes. If anyone can send me an example of an office visit/progress notes form, I would greatly appreciate it, and also a medical history form that the patient completes.
    Thanks for any help you can give me.
    Cynthia Robinson, RT, CPC
    My email address is

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