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Coding Q&A: Office Evaluation & Management Note Questions

Coding ToolsDiagnosis CodesE&M
Mar 15, 2021

Disclaimer: Answers to incoming questions are provided by the members of the Society of Gynecologic Oncology (SGO) Coding and Reimbursement subcommittee and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.

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Can the nurse or office staff document the History of Present Illness (HPI)?

The Documentation Guidelines for Evaluation and Management Services state that the Review of Systems (ROS) and the Past, Family, Social History (PFSH) can be recorded by ancillary staff or on a form completed by the patient. It does not specifically indicate that the History of Present Illness (HPI) can be recorded by staff. It is generally felt that the content of the HPI requires the expertise of a physician or Qualified Healthcare Provider (QHP) to appropriately address the patient’s presenting problem. If the physician is noting changes, additions, or agreement with the HPI then this may be seen as adequate in the event of a payer audit. The physician should be encouraged to make the necessary additions or changes as he/she interviews the patient.


How long can you use the cancer diagnosis (C56.1-9) for a patient once they have completed treatment?

Historically the primary cancer codes were used until the patient had been in remission for 5 years. However recent guidelines state that when the primary has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy at that site, it is appropriate to use the personal history code. Both are recognized for patients who are on surveillance. For patients on treatment, including maintenance, the primary cancer code should be used.


When deciding on the level of Medical Decision-Making complexity, can the MDM be a high level if the physician discusses high risk surgery with many other options but the patient declines the surgery?

Yes, you would code it as if the surgery was elected. The point is not what the patient ultimately decided, but the work done by the physician. Of course, the option for surgery (and thus need for counseling) must be medically appropriate. The medical decision was performed and the patient made a decision based on it.


Do we need to add the acquired absence of organ (Z90.710) to each visit?

It is not necessary on a routine basis unless it is clinically relevant to a particular encounter.


How do I code a cancer patient visit who comes once a year after treatment for surveillance? Is it a “Well Woman visit “or is it a “Follow-up “visit?

If a patient has a history of cancer you could bill an E&M visit using the appropriate ICD-10 codes for the personal history of cancer (for example Z85.41 for cervix) and for medical surveillance following completed treatment Z08. Some carriers will cover E&M visits but not well woman visits or vice versa.

CMS and Medicare guidelines allow for an Annual Wellness Visit once a year (G0438 initial and G0439 established) but only allow a “Cervical or vaginal cancer screening; pelvic and clinical breast examination” (G0101) every 2 years for most women. These are CPT billing codes used instead of an E&M code for the visit. They are reported with an ICD-10 for general gynecology visit (Z01.419). More information may be found on the ACOG and CMS websites.


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If you do not find your answer in the Q&A library, please send your coding question to coding@sgo.org.