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

Article Overview

This coding Q&A article reviews how CPT E/M guidance defines stability for chronic conditions when determining the number and complexity of problems addressed in medical decision making. It is relevant to coders, auditors, and clinicians documenting office and outpatient evaluation and management services, especially when assessing whether a chronic condition supports a low- or moderate-level MDM element. The article focuses on general documentation concepts, the 2023 E/M Guidelines, and how chronic illness status is described in the context of MDM.