“As a general question, I am wondering if a physician documents that the patient has had symptoms for longer than a year and has failed conservative/other treatment, can this problem be considered as “chronic with exacerbation/progression”? I am referring to the verbiage in the CPT book (page 13, under Stable, chronic illness) regarding the expected duration of at least 1 year and am wondering if it is applicable in this scenario. Also, I know that a diagnosis of osteoarthritis is inherently considered “chronic”, but I am wondering if there are other diagnoses that can be considered ‘chronic’, as well?
I have opined since the inception of the E/M changes on January 1, 2021, that the most valuable tool to have in your possession when using Medical Decision Making as the determining factor in selecting the most appropriate level of E/M service is the Level of Medical Decision-Making Table.
Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making in the office and other outpatient services code set is defined by three elements:
1. The number and complexity of problem(s) that are addressed during the encounter
2. The amount and/or complexity of data to be reviewed and analyzed
3. The risk of complications, morbidity, and/or mortality of patient management
Two out of the three elements are required at the proper level to achieve the appropriate level of office or outpatient E/M service. The first element, the number and complexity of problem(s) that are addressed during the encounter is probably the easiest of the three Elements of Medical Decision Making to attain. Listed within this element are several words and phrases that need to be defined and explained further.
- A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
- Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.
- stable chronic illness: A chronic stable problem is one with an expected duration of at least a year/death of patient; a patient at treatment goal is stable.
- acute, uncomplicated illness or injury: Acute, uncomplicated illness/injury is one that is a recent or new short-term problem with low risk of morbidity. There is little to no risk of mortality of treatment and full functional impairment is expected.
- chronic illnesses with exacerbation, progression, or side effects of treatment: Chronic exacerbated is one that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.
- acute illness with systemic symptoms: Acute complicated illness with systemic symptoms has a high risk of morbidity without treatment.
- acute complicated injury: Acute complicated injury is one that requires treatment that includes evaluation of body systems that are not directly part of the injured organ, extensive injury, or treatment options are multiple and/or associated with risk or morbidity.
- chronic illnesses with severe exacerbation, progression, or side effects of treatment: Chronic illness with severe exacerbation includes progression or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.
- acute or chronic illness that poses threat to life or bodily function: Acute/chronic that poses threat to life or bodily function soon without treatment.
If a patient has had symptoms for longer than a year and has failed conservative or other treatment, this is certainly a chronic problem. However, for this chronic problem to be considered as “chronic with exacerbation/progression,” the documentation needs to demonstrate that the situation at hand is “acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.” Otherwise, this problem would be classified as a “stable chronic illness.”
Osteoarthritis is inherently considered to be “chronic.” Based upon the previously listed definitions, there are numerous diagnoses that would be chronic. The bottom line is it must be established whether these additional diagnoses would be classified as “stable chronic” or “chronic with exacerbation, progression, or side effects of treatment.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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