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Posted By Mary Peabody on 03-15-2020, 18:44:56 in Ob-Gyn
Hello Melanie,

On the table of risk, would a diagnosis of endometrial cancer or ovarian cancer requiring open surgery make the risk high under the table of risk? I have a physician that thinks the MDM is high if the patient has ovarian, uterine cancer and requires open surgery and wants to code these visits as 99205.

The same provider thinks that all follow up visits for cancer surveillance be reported using code 99214 for up to 5 years. I tried to explain to the provider that the level of service is based on documentation and not a blanket level of service for follow up for cancer. How can I explain this better to the provider?
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Posted By Melanie Witt on 03-16-2020, 16:23:01
If she has made up his mind, you will have problems with this. Medical decision making can be high if the cancer is life threatening at the time of care (and he also performed a comprehensive exam and history on a new patient. But once treatment has been completed MDM drops from high to moderate immediately following surgery until the patient has recovered from surgery, and then drops further to low complexity if the patient is cancer free. But as you say, the documentation has to make of break it and we are approaching the new rule for 2021 where MDM or total time will be the determining factors.
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