Wiki Chronic exacerbated condition, help!

Create Wiki Sort by votes
S

SUN1633

Networker
Messages
26
Location
Panama City Beach, FL
Best answers
0
We have a provider saying that if a chronic condition has the capability to one day become exacerbated, then it will ALWAYS be counted as a chronic condition with exacerbation. We disagree and say it would have to be exacerbated at this visit. Are we incorrect in understanding everything is from how the patient is presenting today? He is wanting written proof of this.
 
0
That sounds like your provider is asking to get audited. I agree with you 100%. It's only when you do see an exacerbation that you get to code that level. I don't know of any documentation, though, but maybe someone else knows.
 
0
According to our CPT book, chronic illness with exacerbation, progression or side effects of treatment is defined as a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control the progression and requiring additional supportive care. If the patient does not present to the clinic with this type of illness we can't use that level of problems addressed. At the moment, that is all I can find is closely related to your question that may help your provider out understanding it. You could even read that whole section " Number and complexity of problems addressed at the encounter", and that could even give you more information to show your provider. It seems like such as easy thing to explain but finding documentation on it is a bit difficult!
 
0
I was really curious about this now, so I decided to try looking on CMS.gov's site. I found this PDF: https://www.cms.gov/Outreach-and-Ed...ds/eval_mgmt_serv_guide-ICN006764TextOnly.pdf

In the Document Outline, go to Elements for Each Level of Decision Making. Maybe that will help. A huge problem is that your provider's issue is so specific that there doesn't appear to be anything in particular that answers that precise question, but it is how we are taught as coders to look at this.

This is also in the PDF: "To bill any code, the services furnished must meet the definition of the code."
 
Last edited:
1
You can only code and count what you are treating. Just like you can't count an acute illness that may occur in the future, you cannot count an an exacerbation that may occur in the future. What chronic illness doesn't have the capacity to become exacerbated?? Every single DM II or HTN patient who is currently stable and controlled could become a chronic illness with severe exacerbation in the future.
The documentation is in the AMA 2021 guidelines that some other posters referenced.
Specifically, I would point to:
pg 5 Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.
pg 4 Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.
 
You must log in or register to reply here.
Top