Question Stable vs Unstable 2021 Guidelines

Messages
22
Best answers
0
Good Morning. I have a question regarding stable and unstable dx. My providers do not always indicate whether a condition is stable or unstable. For example A/P HTN - Assessment: Comment Only, Plan: Continue current care. Since I can not assume this patient is stable or unstable under Number and Complexity of Problems Addressed do I choose N/A and move on and hope that i can meet the criteria for the other 2 elements with the new 2021 Guidelines. Or is there a guideline that I missed that states default to stable like for DM when they don't document type 1 or 2 you default to DM2.
 

csperoni

True Blue
Messages
1,011
Location
Selden
Best answers
3
If you are continuing current care, that would indicate to me that it is stable. If medication dosage needed to be increased, or additional medication prescribed, that would indicate progression. If BP was so elevated the clinician advised to go to the ER due to risk of stroke, that would be severe progression.

I really like the AMA guide that goes into further depth about this issue. It helped me a lot. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Stable, chronic illness: A problem with an expected duration of at least a 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 medical decision making is defined by the specific treatment goals for an individual patient. A patient that is not at their 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. Examples may include well-controlled hypertension, non-insulin dependent diabetes, cataract, or benign prostatic hyperplasia.
Chronic illness with exacerbation, progression,or side effects of treatment: A chronic illness thatis 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.
Chronic illness with severe exacerbation, progression,or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.
 
Top