Wiki Number & Complexity of problems - adolescent scoliosis

[Vcline515]

Would adolescent idiopathic scoliosis be considered a stable chronic condition or a one with exacerbation, since according to the AMA CPT description: “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, in 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. Examples may include well-controlled hypertension, noninsulin- dependent diabetes, cataract, or benign prostatic hyperplasia." ?
Our spine surgeons are maintaining that this chronic condition should be coded as "moderate" rather than "low" for the number & complexity of problems because in a pediatric patient, the scoliosis is never at the treatment goal and has to be regularly monitored for worsening. I appreciate your input, especially if you can provide references!

 

[csperoni]

The problem in and of itself does not tell you the complexity. The status of the problem at each visit is what determines the problem complexity. If the documentation states that the patient is not at treatment goal, then you can call that chronic problem moderate. However, if there is no treatment goal indicated, or that the patient is not at that goal, then you must default to chronic stable problem as low.
The reference is really what you already posted. "Categorizing MDM is defined by the specific treatment goals for an individual patient." I do not know much about the disease process of adolescent scoliosis, so this example may not be clinically accurate. Let's say the provider established the patient's goal to be < 18 degrees, and the patient is currently at 20 degrees, prior 21 degrees. While they actually improved, they are not at treatment goal. As long as that is in the documentation, then it can be moderate. However, if this is only in the clinician's head, and not on the note, then it cannot be counted. "Monitoring for worsening" does not mean it is not currently at goal, or is actually worsening.