Primary Care Coding Alert

Question: We have a patient with one chronic problem. It is not worsening, but it is also not responding to treatment. Does this mean I count this as a stable chronic illness under number and complexity of problems, and thus report it at a low level in the element of medical decision making (MDM)? If not, how might we document it to make it moderate?

Pennsylvania Subscriber

Answer: The answer to this comes down to how CPT^® describes a patient with a “stable chronic illness.” In the definitions for the elements of MDM for evaluation and management (E/M) services, CPT^® says that “…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.” The definition also goes on to note that chronic conditions may not be stable even “if the patient is asymptomatic. The risk of morbidity without treatment is significant.”

In other words, even if the chronic illness is not worsening, it may not be stable. Instead, consider whether you should classify the condition as a chronic illness with exacerbation, progression, or side effects of treatment, which CPT defines as “A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.” Under the category of the number and complexity of problems addressed element of MDM, a chronic illness with exacerbation, progression, or side effects of treatment is at the moderate level.

When you consider these definitions, as long as your physician has documented the patient’s treatment goals, that the patient is not meeting those goals, and that the patient needs more treatment to achieve those goals, you’re halfway to a moderate level of MDM. Because two of three elements are required to justify any MDM level, if one of the other two MDM elements in the encounter also rises to at least the moderate level, you can go ahead and code 99204/99214 (Office or other outpatient visit for the evaluation and management of a new/ established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making …) for this patient encounter.