Question

question 7

a patient is seen for hypertension. her provider has her on prescriptions, but her blood pressure is not yet at goal. the patient does not exhibit symptoms. when referring to the number and complexity of problems addressed, what type of problem is this considered?

acute or chronic illness or injury that poses a threat to life or bodily functions.
chronic illness with severe exacerbation, progression, or side effects of treatment.
stable, chronic illness
chronic illness with exacerbation, progression, or side effects of treatment.

Explanation:

Analyze the clinical scenario

The patient has hypertension (a chronic condition) and is on prescription medication, but her blood pressure is "not yet at goal." She does not exhibit acute symptoms.

Apply E/M guidelines for complexity of problems addressed

According to the AMA CPT Evaluation and Management (E/M) guidelines for the "Number and Complexity of Problems Addressed":

• A chronic illness that is not at goal is classified as a "chronic illness with exacerbation, progression, or side effects of treatment" (specifically, a chronic illness that is not well-controlled or not at goal is categorized under this moderate complexity level).
• A "stable, chronic illness" requires the patient to be at their treatment goal. Since this patient is "not yet at goal," it cannot be classified as stable.

Match with the correct multiple-choice option

The option "Chronic illness with exacerbation, progression, or side effects of treatment" (which appears as both the second and fourth options in the image) correctly defines a chronic illness that is not at goal.

Answer:

• Acute or chronic illness or injury that poses a threat to life or bodily functions.
• Chronic illness with severe exacerbation, progression, or side effects of treatment. (Correct answer)
• Stable, chronic illness
• Chronic illness with exacerbation, progression, or side effects of treatment.