I can empathise with your situation. I code for five Oncology clinics here in Colorado and it is the same argument I am having here understanding what the oncologists do.
When assigning risk, for the MDM portion I approached it this way with the physician.
For the encounter they are seeing the patient for on that given day:
What is the risk to the patient between now and the next visit -
is the patient at imminent risk of death if the physician does not give them treatment at that encounter (think 1st encounter for a pulmonary embolism, severe thrombocytopenia = High Risk) - are you considering putting them in the hospital at that moment?
Most patient's are eventually going to die of their disease is not treated, but not immenently. So we need to focus on the workup to drive the level.
Moderate would be an established patient with a complaint of constipation.
They probably won't die if they don't get treated and the problem may or may not resolve with treatment from the physician. If the only thing done for the problem is using over-the-counter products and nothing else was done that day, a 99212 is appropriate.
Most patient's in oncology are going to be complex, because there is a lot of work to be done to determine what treatment is going to occur. If the physician get's two points for workup, or more then the patient moves to high complexity of data on the MDM. Most oncologists are going to review records and this gives them 2 points also. Sans, this is enough MDM for a 99205 as long as the other key elements are met for a comprehensive Hx/PE.
They spend an inordinate amount of time answering questions and going over treatment plans, so time documentation is critical. But as a coder we must consider that most of this is just part and parcel of the MDM.
Once the treatment plan is progressing, if the patient is not having complications and is responding, a moderate or high risk is going to be harder to justify. The workup as all ready been done.
Here is what we use to guide us for determining levels of risk:
Ab pain - high risk
Ear pain - Dx otitis media - low-moderate
Embolism followup from admission - moderate
joint point - low
SOB - High (possible embolism w/u)
Chest pain - High
I hope this helps a little.
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