waxing and waning but stable on DOS

smurf

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Patient has 1 diagnosis either atopic dermatitis or psoriasis that is stable on date of service, with med refill. However, provider believes it should be a level 4 because she includes "waxing and waning" in the assessment. Don't we have to go by how the patient presents on the specific date of service? If patient has not gotten worse, stayed the same, or even improving, how can that fall under a level 4? Waxing and waning could apply to a lot of disease conditions.
 

csperoni

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I can't speak to whether or not the documentation demonstrates this, but for chronic problems, if it is not at treatment goal, it is not stable.
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, 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.

Let's say for psoriasis, the documented goal is 60% decrease. Pt returns in 2 months and there is a 40% decrease. It is improved, but still not at goal. Provider states to continue medication for another 2 months. That's level 4 since chronic problem is not stable, and rx management.
A simple statement of "waxing and waning" does not indicate whether or not patient is at treatment goal, or what that goal is.
 

smurf

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Thank you Christine Speroni. Basically, I need to provide feedback to provider that she needs to set a goal for patient's condition in order for this to meet a level 4.
 

csperoni

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Yes, to consider problems at moderate level, it needs to be documented that it's not at goal (or exacerbation, progression or side effects of tx).
 
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