tci E/M Coding Alert - 2024 Issue Q2

Reader Questions: Focus on Treatment Goals to Evaluate Condition Stability

Question: A patient with chronic pain presents for an evaluation and management (E/M) visit. They describe the pain as tolerable, or 4/10 instead of 8/10 in severity, while the medication is taken. Is that condition considered stable or unstable, since the pain level is tolerable but it’s still there and has not resolved? AAPC Forum Participant Answer: CPT® E/M guidelines state that “‘stable’ for the purposes of categorizing [medical decision making] 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...

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