Q1 2024 Urgent Caring – Coding Corner: Documentation and Coding Pearls for Chronic Illness with Exacerbation and Comorbid Conditions

Brad Laymon PA-C, CPC, CEMC
Section Editor, Coding Corner

Chronic Illnesses with Exacerbation

Consider the following examples:

67-year-old male with complaint of “my chronic back pain has flared up.”

He does have a history of chronic back pain and takes Mobic 7.5 mg PRN.

He denies any injury but states it started after raking the back yard for about 45 minutes.

34-year-old female complains of an asthma attack.

She has used her albuterol inhaler with little relief.

She denies any recent URI.

59-year-old male patient who is being seen for a sore throat, but his blood pressure is 168/97.

He does have a history of hypertension.

He takes HCTZ 25 mg daily.

What do these patient complaints have in common?

They all have chronic illnesses which are exacerbated and poorly controlled.

Let’s look at the management of these 3 examples:

67-year-old male with complaint of chronic back pain exacerbation

He will start his Mobic 7.5 mg once daily instead of PRN.

He can use OTC Tylenol PRN.

34-year-old female complains of an asthma attack.

1 albuterol nebulizer treatment was given in the center with improvement in her breathing.

She will continue her Albuterol MDI inhaler 2 puffs every 4-6 hours as needed.

59-year-old male patient who is being seen for a sore throat, but his blood pressure is 168/97.

Discussed elevated BP today. He has not been taking as prescribed.

He will take his HCTZ 25 mg once daily.

He will follow up with his PCP for further evaluation/treatment.

What level of service would you code the above examples? 

The correct level of service for these (with proper documentation) would be level 4 visits…for all of them!

Coding tips for patients presenting with chronic illnesses which are poorly controlled:

• 1 chronic illness with exacerbation + Rx mgmt. = Level 4
• 1 chronic illness with exacerbation + 3 POC tests = Level 4
• Any chronic illness (diabetes, HTN, asthma, chronic pain, eczema, etc.) which is not at treatment goal, and you prescribe or inform the patient to continue their current prescription medication, will be a level 4 visit.
• You must document the chronic illness in the HPI section and have a treatment plan documented in your MDM section.
• As in the third example above, even if the patient is being seen for an illness/injury which is not related to the chronic illness which is not at goal, with proper documentation, these will be level 4 visits.

COMORBID CONDITIONS

When and Why to Use Comorbid Conditions?

The guidelines state, “Comorbidities and underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”

Examples would include:

• The diabetic patient presenting with a foot wound.
• A COVID-19-positive individual exhibiting multiple chronic conditions.
• A cardiac patient experiencing chest pain and shortness of breath.

Examples would NOT include:

• Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the clinician.
• Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the clinician.

Documentation Key Points

It is not enough to just note the patient has a comorbid condition. The guidelines state the condition must be, “addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management“. A problem is addressed or managed when it is evaluated or treated at the encounter by the provider. For example, “BP is 138/88 today. Patient will continue taking HCTZ 25 mg once daily, log BPs daily, and follow up with his PCP for evaluation.” Adding the comorbid condition as a diagnosis is also advised.

Source: American Medical Association. CPT® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. Available at:  www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf