Wiki # and complexity of problem - MDM for obesity

[JMillett]

Hi Again -- boy is this audit proving that there are different ways of interpreting the guidelines. We have auditors telling us that a person seeing a bariatric provider should start with a Moderate complexity if they are obese and have not reached their goal weight, even if they are losing weight. She is considering this a chronic condition that is exacerbated because she has not achieved goal weight. We are arguing that 95% patients would then probably qualify as Mod which would certainly red flag our facility. As long as patient is stable and is losing weight we generally us # and complexity of problems as 1 stable chronic (as long as there are no underlying medical conditions. What are your thoughts?

 

[csperoni]

It is correct that a chronic condition not at treatment goal is considered a moderate problem. From the AMA guidelines (with my emphasis added):
►Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). "Stable" for the purposes of categorizing 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. The risk of morbidity without treatment is significant.

Two items to note:
1) The problem is only 1 element of overall MDM. You must meet moderate data and/or moderate risk to have an overall level 4 visit.
2) ACCURATELY coding more level 4 visits than your peers is not a concern. Perhaps you have more complex patients. Perhaps you have more patients with limits to social determinants of health. Perhaps your clinicians are better at documenting. As long as your coding is accurate, I do not concern myself with potential possible red flags. Undercoding is just as incorrect as overcoding.

How far from the treatment goal could be gray area. If the goal were to lose 25lbs by 10/01/24, and the patient lost 24lbs by 10/01/24, I would not call that problem moderate. If the patient lost 10lb by 10/01/24, they did not even reach 50% of the goal. For gray areas, perhaps your facility could come up with an internal policy. Like at least 85% of goal. Or if the provider is re-educating or changing the overall plan (decrease caloric intake, increase exercise, etc).