tci E/M Coding Alert - 2023 Issue Q2

You Be the Coder: Define ‘Stable’ For Accurate MDM

Question: We have a patient with one chronic problem. It is not worsening, but it is also not responding to treatment. Does this mean I count this as a stable chronic illness under number and complexity of problems, and thus report it at a low level in the element of medical decision making (MDM)? If not, how might we document it to make it moderate? Louisiana Subscriber Answer: The answer to this comes down to how CPT® describes a patient with a “stable chronic illness.” In the definitions for the elements of MDM for evaluation and management...

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