Oncology & Hematology Coding Alert

Hints: “Acute” may not be new, and “chronic” may not be specified by time.

Assigning the appropriate level to the Number and Complexity of Problems Addressed at the Encounter element of medical decision making (MDM) isn’t as simple as adding up the patient’s conditions. You’re going to have to familiarize yourself with the CPT® definitions of some basic terms if you want to quickly and accurately determine whether the office/ outpatient evaluation and management (E/M) service has risen to the straightforward, low, moderate, or high level.

To understand the complexity of problems addressed element, and perform accurate MDM calculations, here are five questions you need to ask before arriving at the most appropriate level.

1. Is the Problem Self-limited or Minor?

Providers don’t use these words exclusively to describe patient problems, so when you’re considering the patient’s condition, think about whether it could have resolved on its own or could have been effectively self-treated without a visit. Examples might be a common cold or a minor injury like a small cut or bruise. From a CPT^® perspective, a self-limited or minor problem is one “that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.”

2. Is the Condition Acute?

Moving to the next level of complexity in the first column of the MDM table, you’ll see three more terms that need defining when you get to the low level of number and complexity of problems addressed: acute, chronic, and stable. Understanding these three terms will help you understand all levels higher than minimal.

One of them — acute — is the subject of some misunderstanding among coders. “I often see coders assuming that ‘acute’ must equate [to] ‘new,’” explained Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas, NV, during his session “E/M Audits for Primary Care” at HEALTHCON Regional 2023 in Washington, DC.

In fact, the condition does not have to be new, as the CPT^® E/M guidelines define an acute, uncomplicated illness or injury as a “recent or new short-term problem with low risk of morbidity for which treatment is considered.” Thus, you can safely interpret “acute” as meaning follow-up to an existing, uncomplicated injury or illness as well as management of a new short-term problem requiring treatment considerations.

So, for an existing acute problem, you should “ensure treatment has previously been initiated and the condition is not fully resolved,” said Swartzwelder. Remember, you’re dealing with alignment with low overall MDM. “Generally, medically necessary follow-up for a resolved condition will align with straightforward overall MDM,” he continues.

3. Is the Condition Chronic?

Chronic is perhaps the slipperiest of all the MDM element terms to define, mostly because no one can agree on a single definition or time frame. For example,

CPT^® guidelines define a stable, chronic illness as “a problem with an expected duration of at least one year or until the death of the patient.”

The Centers for Disease Control and Prevention (CDC) describes chronic diseases as “conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both.”

The U.S. National Center for Health Statistics defines a chronic disease as one lasting three months or more.

Individual specialty associations often have their own definitions. For example, the American College of Gastro­enterology (ACG) does not provide a definition, but does refer to chronic conditions, including chronic liver disease and chronic gastritis, which persist over a long period of time, as often lasting several months.

Ultimately, the best way to define a chronic illness is to follow the guidelines in CPT^®. However, it is also worth following the advice contained in ICD-10-CM Official Guidelines, section I.A.19, which states, “the assignment of a diagnosis code,” and, by extension, the diagnosis code for the MDM level with which it is associated, “is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

So, whether a condition is defined as acute or chronic comes down to your provider’s judgment and how their interpretation and final decision are documented. If the documentation lists acute or chronic, then that is what you will use for code assignment.

4. Is the Condition Stable?

To make matters more difficult, it is also important to remember that chronic conditions can also be listed as “stable” for the purposes of calculating MDM.

CPT^® E/M guidelines state that “‘stable’ for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic.”

This means a patient’s chronic pain could be classified as stable if the treatment goal is to maintain their current pain level with medication. Alternatively, the condition could be classified as unstable if the treatment goal is for the patient to manage their current level of pain without medication.

Ultimately, like the determination for a condition being acute or chronic, the determination for a condition being stable must be found in the documented decisions (i.e., condition, status, and treatment options), which are the responsibility of the provider.

5. Is the Condition Exacerbating?

This term is relatively straightforward and refers to a significant worsening, poor control, or escalation of a patient’s symptoms or conditions. However, use of the term presents its own challenges, as it can be used with chronic conditions at both the moderate or high MDM levels.

Again, the key to assigning the correct level for an exacerbating condition lies in the provider’s documentation. “The treatment plan should correspond with the notes about severity of exacerbation. If you don’t tell me the severity of the exacerbation in the documentation, I have to assume moderate,” said Swartzwelder. In other words, if your provider’s notes are not clear in this regard, use this as an opportunity for education at best, and a query at least.

Consider this: Based on CPT^® definition, if the provider is considering, or has considered, hospitalization, this can represent a severe exacerbation. Once more, if you are uncertain of the exacerbation level, query your physician.