Wiki not responding to treatment--how counted

[wynonna]

If patient has only 1 chronic problem that is not worsening but is not responding to treatment, is this counted as moderate or low under Number and complexity of problems?
If this counts as moderate, what is the best way to document to make it a clear level 4? (if Rx are started or 3 or more tests are reviewed/ordered)
thank you my fellow coders

 

[carlystur]

That would count as a chronic problem with progression (as in continued existence, not severely worsening nor improving). So, level 4 for problems addressed.

 

[TTcpc]

If patient has only 1 chronic problem that is not worsening but is not responding to treatment, is this counted as moderate or low under Number and complexity of problems?
If this counts as moderate, what is the best way to document to make it a clear level 4? (if Rx are started or 3 or more tests are reviewed/ordered)
thank you my fellow coders

Here is information that I use that was presented by the AMA during their symposium last fall introducing the new guidelines: "Stable" is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition is unchanged and there is no short-term threat to life or function." From their education this was to help explain what is considered a chronic stable illness vs. an unstable chronic illness. However they did stipulate that the provider must be clear in their documentation that the patient is not meeting those treatment goals that were set in place.

 

[wynonna]

thank you very much!