Definitions for the medical decision-making elements terminology

Problem

A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.

Examples include nevus, actinic keratosis, seborrheic keratosis, basal cell carcinoma, squamous cell carcinoma, psoriasis, dermatitis, etc.

Problem addressed

A problem is addressed or managed when it is evaluated or treated at the encounter by the dermatologist or NPC reporting the service.

This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or the patient/parent/guardian/surrogate’s choice.

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 dermatologist or NPC reporting the service.

Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed.

Minimal problem

A problem that may not require the presence of the dermatologist or NPC, but the service is provided under the supervision of a dermatologist or NPC.

Suture removal during a nurse encounter (see 99211).

Self-limited or minor problem

A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

Examples may include benign moles, skin tags, itchy bug bite, etc.

Stable, chronic illness

A problem with an expected duration of at least a year or until the death of the patient.

For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes.

‘Stable’ for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

This may include a patient with stable psoriasis vulgaris localized to the elbows and knees, persistent despite topical steroid therapy.

Acute,
uncomplicated
illness or injury

A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness.

Examples may include abrasion, impetigo, etc.

Chronic illness with
exacerbation,
progression, or side effects of treatment

A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.

Examples may include psoriasis vulgaris with new guttate flare, discoid lupus erythematosus with new, active lesions, etc.

Undiagnosed new problem with
uncertain
prognosis

A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.

An example may include a changing pigmented lesion.

Acute illness
with systemic
symptoms

An illness that causes systemic symptoms and has a high risk of morbidity without treatment.

For systemic general symptoms such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general but may be single system.

Examples may include systemic lupus erythematosus with acute diffuse purpuric eruption with fever, headache, or malaise, drug-induced exfoliative erythroderma with shaking chills.

Acute,
complicated injury

An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.

An example may include a head injury with brief loss of consciousness. Extensive injury, or requires evaluation of uninjured body systems, or there are multiple treatment options and/or associated risk of morbidity.

Chronic illness with severe
exacerbation,
progression, or side effects of treatment

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.

Examples may include pemphigus vulgaris with severe cutaneous and oral mucosal/esophageal exacerbation, dermatomyositis with worsening muscle weakness.

Acute or chronic illness or injury that poses a threat to life or bodily function

An acute illness with systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment.

Examples may include Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), toxic epidermal necrolysis, etc.

Test

Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (e.g., basic metabolic panel [80047]) is a single test.

Ordering a test(s) is included in the category of test result(s). As such, the review of the ordered test result(s) is part of the encounter and not a subsequent encounter.

The determination between single or multiple unique tests is defined by the CPT code (e.g., cholesterol [82465], triglycerides [84478] and quantitative human chorionic gonadotropin (hCG) (84702) would each be counted as individual tests when they are not performed as part of the lipid panel). Defined panels of tests (e.g., Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC)) each count as one individual test.

External

External records, communications, and/or test results are from an external physicians, NPC, facility, or health care organization not affiliated with the practice.

Data to be reviewed can also include information obtained from multiple sources or interprofessional communication that is not separately reported (e.g., medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter).

External physician or other qualified health care
professional

An external physician or other qualified health care professional is an individual who is not in the same group practice or is of a different specialty or subspecialty.

It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as in a hospital, nursing facility, or home health care agency.

Independent historian(s)

An individual, other than the patient or physician (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because the dermatologist or NPC determines that a confirmatory history is judged to be necessary.

In the case where there may be conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian(s) requirement is met.

Translators are not considered an independent historian, as they only translate the patient words and are not adding to the history being obtained.

Independent
interpretation

The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the dermatologist or NPC is reporting the service or has previously reported the service for the patient.

Documentation of the interpretation test result must be documented in the patient medical record.

This includes the interpretation and/or reporting of results of tests not ordered by the dermatologist or NPC.

Appropriate source

For the purpose of the Discussion of Management data element, an appropriate source includes professionals who are not health care professionals, but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.

Risk

The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk.

Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as ‘high,’ ‘medium,’ ‘low,’ or ‘minimal’ risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities).

Morbidity

A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.

For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.

Risk also includes medical decision making related to the need to initiate or forego further testing, treatment, and/or hospitalization.

Social Determinants of Health (SDOH)

Economic and social conditions that influence the health of people and communities.

Examples may include food or housing insecurity, lack of reliable transportation to medical appointments, homelessness, etc.

Drug therapy requiring intensive monitoring for toxicity

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.

The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. Intensive monitoring may be long-term or short-term.

Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient.

This may include periodic monitoring of blood and hepatic laboratory parameters during hydroxychloroquine therapy for discoid lupus.

Examples of monitoring that do not qualify, include monitoring quantitative human chorionic gonadotropin (hCG) levels during isotretinoin therapy, even though pregnancy is a concern in female patients of child-bearing age.