This page addresses follow-up questions and additional information pertinent to our webinar
A Deep Dive into Medical Decision Making: Beyond the Basics.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: If a patient come in with an exacerbated chronic condition and improves after treatment, does that then make the condition “stable”?
A: It depends. Stability is based on disease status and treatment goals. A chronic condition can be improved but not yet at stable status. Per the AMA, a chronic condition is considered stable when it is has reached the patient specific treatment goal.
Q: When a patient has systemic conditions such as fever, body aches, or fatigue, how do I determine if this is an “acute illness with systemic conditions“ that meets the moderate bullet in complexity of problems addressed, or if it should be tied to an acute uncomplicated illness?
A: The AMA definition of acute illness with systemic conditions is “An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury.
The thing to focus on here is “high risk of morbidity without treatment.” Does the documentation reflect that these systemic symptoms likely represent a serious issue if it goes unaddressed or is it due a to an illness that acute in nature and will resolve as the acute uncomplicated condition resolves.
A: Per AMA guidelines, the data credit bullet is intended to be applied to external notes and requires notes from an external physician, qualified healthcare professional, or other external source.
Notes from within the same practice are note considered “external” for purposes of receiving data credit. If the two providers happen to be in the same clinic, but are of different specialties, the notes could be considered an external source.
Looking for additional information on this topic?
Meet the Presenter: Emily Lomaquahu, CPC, CPMA, CEDC
Emily is a Senior Coding Quality Auditor for Haugen Consulting Group and brings over a decade of experience to the profee team! She began her career as an auditor and with her keen eye for detail, she quickly found it was a perfect fit. Emily thrives in a collaborative environment and enjoys creating high-quality trainings to help providers and coders navigate charts and improve their accuracy. She earned a bachelor’s degree from the University of Colorado, in Denver. Emily specializes in Evaluation and Management (E/M), Primary Care, Anesthesia, Emergency Department, and Neurology, though she says Anesthesia and Neurology are her favorites! She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and Certified Emergency Department Coder (CEDC).
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