EM Coding Alert

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 stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic.”

In your case, as you describe it, it is not possible to determine whether the patient should be categorized by stable or unstable for MDM purposes as you do not provide information about the patient’s treatment goals. For example, the patient’s chronic pain could be classified as stable if the treatment goal is to maintain their current pain level with medication. Alternatively, the condition could be classified as unstable if the treatment goal is for the patient to manage their current level of pain without medication. So, in this situation, a further discussion with your provider would be advisable.