tci E/M Coding Alert - 2022 Issue Q1

Reader Questions: Rely on Documentation to Prove Management of Chronic Condition

Question: If a patient has only one chronic problem that is not worsening but is not responding to treatment, is this counted as a stable chronic illness under number and complexity of problems? If so, does this rise only to a low level in this element of medical decision making (MDM)? Or is there a way to document it to make it moderate? AAPC Forum Participant Answer: According to CPT®’s definitions for the elements of MDM for office/outpatient evaluation and management (E/M) services, a stable chronic illness “is defined by the specific treatment goals for an...

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