Wiki Meaning of 2 or more stable chronic illnesses under "Number and Complexity of problems Addressed"

[wynonna]

Hello fellow coders:
What is the best way for a coder or insurance auditor to interpret an illness as "chronic but stable" from the documentation?
To have the words chronic and stable spelled out to me is best and I have more than once recommended this for sharp documentation to our physicians. But I'm not seeing it spelled out. Instead I see allergic rhinitis, hearing loss, tinnitus, eustachian tube dysfunction, dysphagia, obstructive sleep apnea, facial pain, hoarseness, vertigo, nasal turbinate hypertrophy, deviated nasal septum and the like without any documentation as to whether problems are acute or chronic. We are ENT.
In the absence of the words stable or chronic, is there a default? I look but can't always find stable or chronic in Assessment/plan nor HPI.
I sometimes look through past visits to see if the patient has had the same problem for more than a year and I view this as a chronic illness.
But an insurance reviewer may not want to do that or may feel problem needs to be spelled out as chronic.
Any ideas how to best interpret stable and chronic illness? and how to teach physicians to document this appropriately?
Thank you

 

[jkyles]

For office E/M visits, the new definition gives pointers to the sort of information doctors need to include in the note and what coders should look for:

Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the
patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or
severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition).
“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, in 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, the risk of morbidity without treatment is significant.
Examples may include well-controlled hypertension, noninsulin- dependent diabetes, cataract, or benign
prostatic hyperplasia.

I don't think it is too much to ask for a doctor to note the problem is chronic and whether it is well or poorly controlled, but doctors may disagree.