Pregnancy - chronic or acute problem for Medical Decision Making?
As of January 1, 2021, E/M code selection for CPT codes 99202-99215 may be based on time or medical decision-making (MDM). One of the elements used in selecting the level based on medical decision-making is diagnosis. This refers to the number and complexity of problems addressed at the encounter.
The CPT 2021 guidelines reference chronic and acute problems. The CPT definition of a chronic problem is one with an expected duration of at least one year. The SMFM Coding Committee has received several questions regarding whether pregnancy is considered a chronic or acute problem when coding based on medical decision-making.
It is the opinion of the committee that pregnancy is considered a chronic problem. Let us delve into this explanation further. If one considers that gestation is 10 months (40 weeks) give or take, and then the postpartum period is 6-12 weeks give or take then the care of the patient under an MFM could potentially exceed 1 year during which pregnancy related problems could occur. In addition, the definition of chronic disease/chronic problem is one that needs ongoing medical care and can limit a woman's usual activities or daily life. None of us would argue that Pregnancy most certainly fits these concerns. Management of pregnancy, even an uncomplicated one, inherently requires more physician management and supervision than an acute, uncomplicated illness or injury. In the definition of a chronic problem the CPT guidance states that risk of morbidity of this condition without treatment is significant.
Pregnancy requires treatment/management/supervision, such that most of us agree that without treatment morbidity and perhaps actually mortality is HIGH. On the other side, let us discuss an acute uncomplicated problem and why pregnancy does NOT fit this condition. Acute, uncomplicated illness or injury is defined by CMS as recent or new short-term problem; pregnancy is ongoing, and not short-term. There are more frequent visits over a span of 10-12 months than a simple one-time acute problem visit. Considering pregnancy an acute, self-limited process would mean that it has a low risk of morbidity for which treatment is considered. As we stated above this does not seem to fit. We hope this provides clarity to this question. If the AMA provides any updates or clarification, we will notify membership as soon as possible.