tci General Surgery Coding Alert - 2022 Issue Q2

You Be the Coder: Define Stable Chronic Illness

Question: Our surgeon performed sinus surgery for a patient referred due to chronic sinusitis. Several months later, the patient returned with recurring sinusitis. For the evaluation and management (E/M) visit, should this be considered a chronic problem that is stable, thus rising only to a low level in this element of medical decision making (MDM)? Kentucky Subscriber Answer: No, this would not count as a stable chronic problem. According to CPT®’s definitions for the elements of MDM for office/outpatient E/M services, a stable chronic illness “is defined by the specific treatment goals for an individual patient...

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