Selecting High vs. Moderate Risk

Question: I have kind of a technical question for you. Under the Diagnostic Procedure(s) Ordered column on the Table of Risk you have:

• Moderate - Cardiovascular imaging studies with contrast and no identified risk factors, e.g. arteriogram, cardiac catheterization

• High - Cardiovascular imaging studies with contrast with identified risk factors

A cardiologist orders a Myoview stress test, a nuclear study on a patient with an abnormal EKG to rule out coronary artery disease. The patient also has diabetes mellitus, hypertension, hypercholesterolemia, which are all stable at the time. Are these additional risks adequate to select a high risk?

Endoscopy has the same distinction relative to risk factors - moderate versus high risk. I never really know what to do about this. I have asked this question of several coders and no definitive answer has been given.

Answer: There’s a reason that coders have likely been unsure here, and it’s because they probably don’t have a good sense of the risk that any given comorbid condition creates.

The middle column of the Table of Risk is tricky for two reasons: First, it contains examples of things that may represent a given level of risk (like the entries in the other columns), rather than a definitive measurement; and second, it depends on a given provider’s opinion relative to what risk is entailed with a given procedure, and may more importantly depend on the ability of a nonclinician auditor to recognize it.

Simply ordering a given test, and mentioning comorbid problems likely does not resonate with all reviewers, or resonate the same with all other clinicians. In my opinion what you need to do is to make a clear statement that the patient is at a given level of risk, use the words “moderate” or “high,” relative to a specific differential, diagnosis, or procedure.

In a Medicare document outlining medical necessity requirements we find the following statement: “Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent, and risk to the patient) was affected by comorbidities or chronic problems listed.”

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the July/August 2010 issue of Physicians Practice.