Number and Complexity of Problems Addressed

Question:

I see a lot of patients with chronic pain and other issues. What defines “stable” vs. “exacerbation or progression”?

Answer:

Number and Complexity of Problems Addressed

Per the CPT guidelines, ‘stable’ for the purposes of categorizing medical decision-making is defined by the specific treatment goals for an individual patient. A patient who 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.

A chronic illness with exacerbation, progression, or side effects of treatment is a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control the 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.

For all E/M codes, while it doesn’t contribute to code selection, documenting the history of the present illness (HPI) is crucial documentation. The provider must document each problem addressed and indicate stable, acute, chronic, exacerbation, etc., for each problem. Incorporate the terms exacerbation (getting worse) and severe exacerbation (getting significantly worse, requiring significant treatment changes) in your assessment when applicable. Be sure to document a recommendation (plan of care) for each problem addressed (i.e., stable, make changes, order additional testing).

*This response is based on the best information available as of 11/17/24.