Terry discusses how to be accurate in your documentation when picking the low, moderate or high element(s) of MDM.

When listing “problems addressed” in your E/M record, and considering chronic conditions, the definition of a stable, chronic illness, per AMA/CPT states, “stable” to categorize MDM as defined by the specific treatment goals for an individual patient.

A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. By this definition, a patient might be living with a chronic condition that is controlled.

However, if they are falling short of their treatment goals, they would not be considered “stable.”

This shows that the spirit of the new AMA/CPT E/M Documentation rules are about patient-centered care and that every patient has a unique set of goals and circumstances: achieving these personalized objectives truly determines “stability.”

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