I have been in the healthcare field for more than 35 years, and remember when we didn't have Evaluation and Management (E/M) codes. Then, we went through the 1995 and 1997 guidelines from CMS. All the elements, boxes, borders – UGH! Now, we have a cleaner way to document E/M services with the 2021 and 2023 updates.
At first, I heard comments on how easy the new guidelines are and how physicians/APPs would make the transition seamless. Well, we are a couple of years in now, and I continue to see issues when I audit records documenting a chronic exacerbated condition. Many times, a physician/APP credits the chronic exacerbated condition when factoring in their E/M level choice but doesn't document to support it.
A stable chronic condition is pretty straightforward. It is a chronic condition that is managed, stable, and predictable, such as hypertension or diabetes, with no appreciable change. Clarifying this can be intuitive in many instances. For example, a patient with well-managed hypertension whose blood pressure readings and symptoms are under control would be considered a chronic, stable condition. The patient is at the treatment goal for that condition on the encounter date.
However, a hidden gem is given to us to consider with chronic conditions in the CPT E/M definitions. In the definition of a stable, chronic illness, CPT states, "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." By this definition, a patient might be living with a chronic condition that is controlled, but if they are falling short of their treatment goals, they would not be considered 'stable.' For me, this emphasizes that every patient has a unique set of goals and circumstances, and achieving these personalized objectives truly determines 'stability.'
Consider a patient with type II diabetes who, despite having consistent glucose readings within a commonly acceptable range, struggles to bring them within the target his healthcare provider established specifically for him based on his health condition and lifestyle. Under the CPT E/M definitions, this patient's condition would still be considered unstable or exacerbated.
This shift towards patient-specific goals within the CPT E/M guidelines poses an opportunity and challenge for auditors. Ensuring the capture of these individualized treatment objectives in documentation is key. Auditors can ensure coding accuracy by being aware of and understanding this nuanced perspective of 'stability' - as tied to the individual's treatment goals.
When auditing a record to support a condition as chronic exacerbated (not stable), here are some things to look for in the record:
- The treatment goals outlined for patients with chronic conditions are evident and well-documented (It could come into question if a physician/APP documents "asthma not at goal" but no goal is noted or mentioned in the record).
- These goals are evaluated and updated continuously, aligning with the patient's progress and condition.
- Instability in a condition is classified not only considering the apparent severity or changes in a condition but also in relation to the patient-specific treatment goals.
The expanded definition of 'stability' adds another layer for auditors to review and allows auditors to educate providers. In a way, it transforms the role of an auditor from spotting and rectifying inaccuracies in coding and documentation to being a vital link that binds patient-centered care and appropriate revenue cycle management.
By Betty Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC- Compliant Health Care Solutions
Betty A Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is a nationally recognized healthcare consultant and speaker. She is an expert auditor and loves to help practices stay compliant and profitable. Betty states, "Physicians work hard for their practices and they should be paid properly for what they do."
Betty brings over thirty years of healthcare experience. She has worked for practices both large and small with the same intensity and attention. She has spent years on the "front lines" for practices handling medical billing, coding, claims, and denials. She has also managed practices and directed healthcare system departments. Her areas of expertise include Evaluation and Management, Primary Care, Dermatology, Plastic Surgery, Cardiology, Cardiothoracic Surgery, General Surgery, GI, E/M and procedural auditing, and ICD-10-CM.