Information about a condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.

Data Element

Information from the submission form

Disease Trend
Description
Disease trend, also referred to as disease status, represents the clinician's overall judgment on the current trend of a condition, e.g., whether it is stable, worsening (progressing), or improving (responding). The judgment may be based a single type or multiple kinds of evidence, such as imaging data, physical examination, tumor measurements, laboratory data, etc. The condition trend can be reported multiple times during the course of a condition, each report representing the clinical judgement at that point in time. The element is important in assessing disease progression and determining the efficacy of treatments.

Comment

Note that the disease trend…

Note that the disease trend/status is a required part of CPT Evaluation and Management (E/M) guidelines required for clinical documentation for new and established office patients. These guidelines were updated by the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) and went into effect on January 1, 2021. Patient disease status/trend is required for determining complexity of medical decision-making (MDM) for a given patient encounter. For example, when assessing the nature and number of clinical problems, some of the ways clinicians are asked to categorize disease processes are:
  • Self-limited or minor
  • Established problem, stable or improved
  • Established problem, worsening
  • New problem, no additional work-up planned
  • New problem, additional work-up planned
............ This submission is made on behalf of CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator community of professional medical societies, health systems, industry and others seeking to achieve interoperability via the mCODE (minimal Common Oncology Data Elements) standard in order to drive step-change improvements in cancer patient care and research. https://confluence.hl7.org/display/COD/CodeX+Home

Log in or register to post comments