This week I want to continue our discussion on coding terminology. More specifically, how sometimes we as doctors don't understand the medical terms used by coders. This week I want to talk about the difference between acute and chronic problems, especially as it applies to risk.
Let's take the following three patients:
Patient #1 is here for follow-up of pneumonia. She was started on antibiotics 4 days ago but now is having severe diarrhea and stopped her medicine yesterday.
Patient #2 is here for follow-up of strep throat. He was started on antibiotics 2 days ago but still having severe throat pain and decreased po intake.
Patient #3 is here for follow-up of diabetes. His disease is now complicated by the fact that he takes his medication only sporadically and hasn't checked his blood sugars in over a month.
When trying to assess for risk, we have chronic problems and acute problems. Chronic problems are always either stable or have mild, moderate, or severe exacerbation, progression, or side effects. When we talk about acute problems, we can have acute uncomplicated (low risk), acute complicated (moderate risk), acute illness with systemic symptoms (moderate), abrupt change in neurologic status (high risk), or life-threatening (high).
But you don't get to mix and match these! Here's what I mean. With patient #1, I'm tempted to say she is now having mild side effects so that makes her moderate risk. On patient #2, it seems that he is still having symptoms (mild exacerbation) so moderate risk also. And patient #3 is now complicated by noncompliance so that makes him moderate risk as well.
The risk may be correct, but the reasoning is wrong. There is no level of risk associated with an acute problem with mild side effects. There is no risk level for a complicated chronic problem. So what would be the correct level of risk?
Patient #1 has an acute complicated illness. Even though it is day 4, this is still an acute problem but it is complicated by side effects and non-compliance. This is moderate risk.
Patient #2 also has an acute complicated illness. Also moderate risk.
Patient #3 has a chronic illness. It could be stable (low risk) or he could have mild/moderate/severe exacerbation. You just have to check his blood sugar or HgbA1c to decide how much exacerbation he is having. This could be low, moderate, or high risk.
Hope this helps you when discussing your documentation with coders. Good luck with your practices.