I’m looking for clarification regarding the correct definition of "the nature of the presenting problem" and how chronic conditions without current exacerbation relate to the level of evaluation and management service. I’ve seen providers coding level 5 follow-up office visits for patients with debilitating chronic conditions that are stable with no current complaints. These are conditions like cerebral palsy, cognitive and functional impairment, Ehlers-Danlos syndrome, cystic fibrosis, etc. The physician may document medication changes or recommend new therapy. My understanding is that, regardless of how chronically ill a patient is, if they are currently stable and at their personal baseline, even though that baseline may be a pretty severe impairment, it is not appropriate to code a level 5 for routine follow-up with adjustments to the treatment plan and/or medication management. I’ve had colleagues argue that the underlying condition itself can be severe enough to complicate medical decision making to the extent that high complexity is supported, even without a current exacerbation, but I am unable to find any guidelines that address this specifically. Both 99214 and 99215 state "usually, the presenting problem(s) are of moderate to high severity". Does "the nature of the presenting problem" refer to the patient’s overall or underlying physical condition, or is it specific to the signs/symptoms or concerns present at the time of the encounter only?

Thanks