Wiki Subjective exacerbation

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Sarah Ann

Sarah Ann

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Concord, NH
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I was told today the provider doesn't have to state "exacerbation" or "flare "or worsening- because the provider documents "the patient feels it's an exacerbation of her illness." Ok, but objectively what is the provider finding? I personally don't (for E/M purposes (leveling) unless the provider documents it is an exacerbation or flare of etc. Then in the final they only document for example "asthma" Am I wrong all of the sudden? Oh and by the way we don't query doctors- they go through a coder, we'll get answers like the above.
 
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If "asthma" is the only thing the doctor documented, then that's all you can code to for dx but interesting question on MDM. Thinking out loud, what if the patient-stated exacerbation/progression had been pain. The doc can't objectively point to or assign severity just by pt saying so but depending on the situation and the rest of the HPI, I would use that to help determine the MDM/problem. How much pain would be normal and at what point could it signal progression (further testing?). In the asthma example, is pt having SOB with exercise? May be normal. Never had SOB before doing the same exercise? May be progression. If the doc didn't advise on additional meds, behavioral modification, or testing, I don't think I would consider exacerbation. I have definitely determined something to be an exacerbation without the doc specifically stating "exacerbation" but most times it's pretty obvious by the HPI/meds/testing. It's tough when you can't query. This would be a great roundtable debate. I'm interested to see others weigh in.
 
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When we're talking about level of the problem, I expect my providers to clearly document if the problem is not stable. Absent that, I consider chronic problems stable.
Patient thinks it's an exacerbation is not the provider's assessment of the problem.
What if the note said "Patient thinks she has appendicitis"? Or "Patient thinks she broke her left thumb."? Without the provider's diagnosis, it's not coded.
 
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