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.
