Clarifying Diagnosis Definitions for Medical Decision-Making
June 5, 2023
Having a clear understanding of diagnosis definitions is obviously important to medical decision-making, accurate documentation, and reimbursement. Unfortunately, the guidelines in the AMA grid—which only refer to 1 acute, uncomplicated illness or injury—aren’t particularly helpful.
Here is a valuable resource for you as you seek to assign the proper diagnosis for MDM.
Minimal problem: A problem that may not require the presence of the physician or other qualified healthcare professional, but the service is provided under supervision by the physician or other qualified healthcare professional.
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 the patient’s health status.
Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not their stage or severity change (e.g., uncontrolled diabetes and controlled diabetes are regarded as a single chronic condition). “Stable” for the purposes of categorizing MDM is 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. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
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 not resolving in a manner consistent with a definite and prescribed course is an acute, uncomplicated illness.
Acute, uncomplicated illness or injury requiring hospital inpatient or observation-level care: A recent or new short-term problem with a low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation-level setting.
Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may be incomplete, stable with respect to this condition.
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 the progression and requiring additional supportive care or requiring attention to treatment for side effects.
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.
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, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system.
Acute, complicated injury: An injury that requires treatment that includes evaluation of body systems not directly part of the injured organ, or in which the injury is extensive, or the treatment options are multiple and/or associated with 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 a significant risk of morbidity and may require escalation in level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, 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. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.
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EVP, Regulatory Coding Compliance