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Coding Corner: Defining “Medical Procedures with Patient or Procedure Risk Factors” | Jhalak Dholakia, MD

Jul 18, 2023

Jhalak Dholakia, MD

As part of systemic changes to outpatient evaluation and management (E&M) billing and coding, decision-making based on patient and procedural factors can be included in determining CPT codes. Level 5 (99205/99215) or ‘High’ billing requires that two of three elements meet increased complexity requirements. These elements are:

1) Number and complexity of problems;

2) Amount and complexity of data;

3) Risk of complications and/or morbidity/mortality.

Many patients in a gynecologic oncology clinic, by definition, meet ‘high’ complexity criteria for element 1: either one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment OR an acute or chronic illness/injury with threat to life or bodily function.

Defining element 3 can be more challenging, especially in the context of pre-surgical/procedural counseling for major procedures or initiation of a new therapeutic agent. In both cases, however, this requirement would be met with clear documentation of either patient factors (namely, medical co-morbidities) or risks of the intervention that demonstrate high risk. If these requirements are met and clearly documented, level 5 billing would be appropriate. Note that the final treatment plan is not part of E&M billing.

Scenario 1: A patient with recently diagnosed recurrent cervical cancer presents for treatment counseling. You counsel her on treatment with tisotumab vedotin, including the need for frequent eye examinations and outpatient management due to the high risk of toxicity. You document her recurrence to meet element 1 requirements, and the high risk of morbidity requiring intensive monitoring to meet element 3 requirements.

Scenario 2: A patient presents for counseling regarding surgical management of biopsy-proven endometrial cancer. She has a BMI 55, chronic hypertension on two agents, and type 2 diabetes with A1c 8.5. You counsel her on surgical options including a minimally invasive approach to decrease peri-operative morbidity in light of her co-morbidities. You also counsel her on the risk of conversion to an open procedure as well as the risk of operative complications specific to the procedure. Documentation of her oncologic diagnosis meets element 1 requirements, and counseling regarding high risk of complications due to her co-morbidities and the complex nature of the procedure meet element 3 requirements. Note that, without medical co-morbidities, this counseling would only meet Level 4 requirements for element 3.

Scenario 3: A patient with symptomatic recurrent granulosa cell tumor presents for counseling. She has had multiple prior abdominal surgeries unrelated to her malignancy and a history of COPD with prolonged intubation after her most recent surgery. You determine that she is appropriate for secondary cytoreduction and counsel her accordingly, including discussion of the potential morbidity of surgery. She declines further treatment and opts for supportive care. Documentation of her disease status and symptoms would fulfill element 1 requirements.

Documentation of counseling regarding major surgery including patient risk factors would fulfill element 3 requirements. Note that in this scenario, level 5 billing applies even though the patient did not elect for the discussed treatment plan.


For further details and examples, please reference the following resources:

· American Medical Association. CPT® Evaluation and Management (E/M) Code and Guideline Changes. January 1, 2023.

· Society of Gynecologic Oncology. 2023 Spring Coding Webinar: Office Coding: Complex Cases. June 22, 2023.


Jhalak Dholakia, MD, is a gynecologic oncology fellow at the University of Alabama at Birmingham.