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Wiki AWV/Preventive + Problem E/M with Modifier 25 — chronic conditions marked “stable”

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KoBee

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Hi all,
I’m looking for peer input because I’m seeing conflicting information and varying provider expectations.

Scenario: During an AWV (or a Preventive 99381–99397), a provider documents one or more chronic conditions as “stable,” continues the same meds, and doesn’t perform additional work (no new data review beyond routine, no change in plan, no expanded exam, no additional risk assessment beyond AWV/Preventive requirements). Some providers still want to bill a separate problem‑oriented E/M (99202–99215) with modifier 25, stating they “managed a chronic condition.”

My position: Simply noting a stable condition and continuing medications doesn’t, by itself, meet the bar for a significant, separately identifiable E/M service beyond the AWV/Preventive. I’m pushing for documentation that shows additional, distinct work (history/exam/MDM) to justify a separate problem visit.

Are others encountering pressure to add an E/M + modifier 25 in this “stable chronic” scenario?

Any education pearls or templates you’ve shared with clinicians to improve clarity?
 
KoBee said:
Hi all,
I’m looking for peer input because I’m seeing conflicting information and varying provider expectations.

Scenario: During an AWV (or a Preventive 99381–99397), a provider documents one or more chronic conditions as “stable,” continues the same meds, and doesn’t perform additional work (no new data review beyond routine, no change in plan, no expanded exam, no additional risk assessment beyond AWV/Preventive requirements). Some providers still want to bill a separate problem‑oriented E/M (99202–99215) with modifier 25, stating they “managed a chronic condition.”

My position: Simply noting a stable condition and continuing medications doesn’t, by itself, meet the bar for a significant, separately identifiable E/M service beyond the AWV/Preventive. I’m pushing for documentation that shows additional, distinct work (history/exam/MDM) to justify a separate problem visit.

Are others encountering pressure to add an E/M + modifier 25 in this “stable chronic” scenario?

Any education pearls or templates you’ve shared with clinicians to improve clarity?
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One thing you could do is have the provider divide the documentation. Have them mark everything for the E/M-25 only and not related to the other service such as AWV. After that you could look at the documentation and see if it "stands on its own". If the documentation for the AWV was not there, would you be comfortable coding and billing as documented? Is just the word "stable" adequate for documenting the current status of that condition? Another item to consider is the use of the word "stable". In the documentation guidelines it states that a condition is not stable if the treatment goal is not met. Is the patient's medical condition at goal and not expected to get better?
 
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