Primary Care Coding Alert

Question: Our provider saw a patient with diagnosed celiac disease. I’m trying to level the encounter using medical decision making (MDM), and the provider has written that the patient’s condition is not worsening, but it’s also not improving. Because it’s not getting worse, does that mean the celiac disease is stable?

Massachusetts Subscriber

Answer: Whether the patient’s condition is stable is going to depend on the documentation. Currently, a strict, life-long, gluten-free diet is the only treatment for celiac disease, which means patient compliance will often determine how stable the condition is.

Let’s first look at how CPT^® describes a patient with a stable chronic illness. Under the definitions for the elements of MDM for 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 celiac disease is not worsening, it may not be stable. Without information on the patient’s baseline condition, or even how the patient was at the last visit compared to now, it’s hard to offer a definitive answer. If the documentation states that the patient’s condition has not improved since the last encounter due to lack of adherence to a gluten-free diet, that likely doesn’t align with the treatment goals and therefore the condition is not stable. However, if the patient was diagnosed a year ago, complied with the diet, met treatment goals, and has therefore stayed symptom-free, then the condition is likely stable. Treatment goals are met, being maintained, and can’t really get better.

Bottom line: Celiac disease, like many chronic conditions, can’t be assigned as stable or unstable without additional information that is unique to each patient. Physician judgment is the key, and that thought process should be clear on the medical notes. If it’s not, that’s an opportunity for a query.