I just completed a private talk for a group of doctors in Atlanta last night. I was thinking about my last newsletter and the discussion we had about 'risk'. About how it is not always what a doctor THINKS that risk is. It is a term defined very explicitly in the Medicare guidelines. Many times we can find ourselves trying to 'convince' or 'talk our coder out of' a certain level of service. Talking with several physicians and professional coders last night I came to a realization.
And suddenly it was very clear why we have so many communication problems. Over the next few newsletters I'm going to try to straighten this out. Now, this may come as a shock to some of you doctors out there so I'm just going to say it: You have to learn new definitions for some words. You will not be able to convince your coder or auditor to learn your definitions. Think of it just like the old days. Remember when you had to learn what abductor policus longus meant? This is the same thing.
Here are some of the words that we have trouble with: risk, acute, chronic, stable, progression, drug management. You will recognize some of these terms from previous questions and answers. We talked about risk in the last newsletter. Today we are going to talk about the term 'stable.'
In the risk table, 1 stable chronic problem is considered low risk and 2 stable chronic problems are considered moderate risk. No amount of stable chronic problems will ever be considered high risk (sorry, that would be too easy to code level 5's then). As a doctor, my definition of stable is something like 'not any worse than last time.' This is NOT the definition of stable if you are a coder.
Let's take three patients:
Patient #1 has chronic asthma controlled with Advair, Singulair, and prn albuterol. She comes in today for 3 month follow-up. In the last 3 months her peak flow measurements have been over 75% and she uses albuterol on average maybe once per week.
Patient #2 has hypertension. He takes Coreg every day. Last time he came in his blood pressure was 150/90. He hasn't checked it really in the last month at home. Today he comes in asymptomatic and his blood pressure is 150/90.
Patient #3 has depression. He has been taking Prozac for 3 months now with resolution of all his depressive symptoms. He has gained 8# since his visit last time but doesn't complain of any side effects.
From my medical point-of-view, I would consider all of these patients 'stable.' According to that, each would have a low level of risk and probably have 99213 office visits. But none of these patients are stable from a coding stand point.
Remember 1 stable chronic problem is considered low risk. But in the moderate risk category we have 1 chronic problem with mild exacerbation, side effects, or progression of disease. This is the coding definition of stable. From a coding point-of-view a stable chronic problem is one with no exacerbation (symptoms of disease), side effects (symptoms of treatment), or progression of disease.
So what does that mean for our 3 patients?
Patient #1 First off, the asthmatic has at least mild progression of disease because it is taking 3 medications to control his chronic disease. So I want to indicate this to my coder/auditor in one of two ways. In my HPI I can put something like 'Patient is here for follow-up of asthma with mild/moderate disease progression (currently taking Advair, Singulair, and albuterol)'. Or when you list your diagnoses for the note put something like: "1. Asthma (493.90) (mild progression)". I usually do both. But then when you start discussing with your auditor it will be very clear why you chose a moderate level of risk. But it is only clear if you understand their definitions!
Patient #2 is having mild symptoms (his blood pressure is still elevated). So my HPI would say 'Patient is here for follow-up of hypertension. Currently still having mild exacerbation (BP 150/90 today).' Then my diagnoses would list "1. Hypertension (mild exacerbation)".
Patient #3 would be very similar: 'Patient here for follow-up of depression. No exacerbation. Is having mild/moderate side effects (8# weight gain).' Then my diagnoses: "1. Depression (mild side effects)".
Next week we will talk about acute versus chronic. If you have any terminology issues that you've found problems communicating with your coder about, please email and let me know.