Accurate documentation of the comorbidities and complications of patients with cancer does more than just guide clinical care and support reimbursement, it directly informs the medical codes that drive large-scale cancer research and population health insights. When documentation is incomplete or unclear, the ripple effects extend far beyond the individual patient. Here are some practical strategies to ensure that your records translate into meaningful data to help improve patient care and research.
Collecting and Reporting Data on Comorbidities Matters, Can Be Challenging
Documentation of patients’ comorbidities in the medical record supports reimbursement claims for higher-paid Evaluation and Management (E/M) codes and for separate E/M CPT codes on the same day as treatment, as indicated by modifier 25. In short, they corroborate the severity and complexity of a patient’s illness, which speaks to medical necessity.
Oncologists face multiple challenges in documenting comorbidities, explained Jay F. Piccirillo, MD, an otolaryngologist, clinical epidemiologist, and health services researcher practicing at Washington University in St. Louis. “Many symptoms of comorbid conditions can overlap with those of cancer, making accurate attribution difficult,” he said.
Dr. Piccirillo offered a list of symptoms that are common to both cancer and other conditions: