Question Improving conditions- MDM coding

carriganm

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I have a question on coding the 'Number and Complexity of Problems Addressed' More often than not patient comes in for a follow-up of their chronic conditions and in the assessment it states that patient is seeing improvement and to continue their rx or OTC. How do I code this? There are no data points to be counted and 2/3 categories need to be met. In my opinion 'improving' doesn't fit any of the definitions in the complexity area. Below is an example of a chart note I'm currently stuck on. Any help would be extremely appreciated. Thanks! .

1. Gastroesophageal reflux disease-
Patient noting improvement with use of DGL tablets. I advised him that we will need to do this for several months prior to trying to discontinue the pantoprazole so I recommended that he continue that but can use it on an as-needed basis as he did previously. We will see him back in 2 months and look at trying to wean the pantoprazole at that point.
K21.9: Gastro-esophageal reflux disease without esophagitis

2. Iron deficiency anemia-
Improvement in overall energy with current iron therapy and even noting improvement in sleep. We will continue his current iron therapy and recheck his iron studies in 2 months prior to his follow-up visit.
D50.9: Iron deficiency anemia, unspecified
 

kimberlywatson

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For the "Number and Complexity of Problems Addressed" section, I would count "1 or more chronic illnesses with exacerbation, progression, or side effects of treatment" since you have two unstable chronic illnesses. Keep in mind, the AMA states that a patient is not stable if they are not at their treatment goal. In your case above, while the patient is indeed improving on each issue, they are not yet stable per definition. Additionally, since the provider is managing prescription drugs, you have a moderate risk. Therefore with a moderate complexity and a moderate risk, you have a 99214 visit. Hope that helps!
 

carriganm

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For the "Number and Complexity of Problems Addressed" section, I would count "1 or more chronic illnesses with exacerbation, progression, or side effects of treatment" since you have two unstable chronic illnesses. Keep in mind, the AMA states that a patient is not stable if they are not at their treatment goal. In your case above, while the patient is indeed improving on each issue, they are not yet stable per definition. Additionally, since the provider is managing prescription drugs, you have a moderate risk. Therefore with a moderate complexity and a moderate risk, you have a 99214 visit. Hope that helps!
That is exactly what I needed to know! I knew that I couldn't count it as stable because of the AMA guidelines. Good to know that I can count it as a "chronic illness with exacerbation, progression or side effects of tx" category. I've always looked at that as if it implies the condition is worsening. But, reading it after your explanation it makes sense as it is progressing, but not progressing as worsening but progressing as in improving. Hopefully I'm analyzing that correct. Thanks again!! :)
 

kimberlywatson

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Sure thing! Improving conditions have always been tricky for me as well! In regards to "progression", I don't think it includes progressing as in improving. But essentially, anything less than the treatment goal could be considered an exacerbation. That, along with the stable definition, is how I decide. I wish "1+ unstable chronic conditions" was an option :)
 

carriganm

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Sure thing! Improving conditions have always been tricky for me as well! In regards to "progression", I don't think it includes progressing as in improving. But essentially, anything less than the treatment goal could be considered an exacerbation. That, along with the stable definition, is how I decide. I wish "1+ unstable chronic conditions" was an option :)
Okay Kimberly see this example below. It is these ones that I have a hard time counting as exacerbation. But it's not stable so it sounds like I should go ahead and count it as that. Then with that along with the RX I could get a 99214. Would you agree?
1615218300972.png
 

kimberlywatson

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@carriganm yep!! With only "modest improvement" the patient is not at the treatment goal so there are still exacerbations (or aka it's unstable). He's also adding to the medication which makes it moderate risk. So 99214 it is! :)
 
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