I can't speak to whether or not the documentation demonstrates this, but for chronic problems, if it is not at treatment goal, it is not stable.
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.
Let's say for psoriasis, the documented goal is 60% decrease. Pt returns in 2 months and there is a 40% decrease. It is improved, but still not at goal. Provider states to continue medication for another 2 months. That's level 4 since chronic problem is not stable, and rx management.
A simple statement of "waxing and waning" does not indicate whether or not patient is at treatment goal, or what that goal is.