MDM – New Problem to Examiner or Patient?

MDM – New Problem to Examiner or Patient?

When calculating an evaluation and management (E/M) level or auditing an E/M service, every Medicare Administrative Contractor (MAC) has always had the points assigned for a new problem under the Number of Diagnoses or Treatment Options based on a new problem to the examiner. This means that, although a problem may be established for a patient, if it is new to a provider, they get the higher points assigned for a new problem (3 or 4) as opposed to an established problem (1 or 2).

I recently downloaded an E/M Training Tool from NGS Medicare Services for a client who is in New York and immediately noticed that the Jurisdiction K – Part B MAC indicates that the new problem is to the patient, not to the examiner. This is a deviation from other payers.

Patient vs. Examiner

The MAC’s Medical Decision Making Frequently Asked Questions (No. 34) explains why the change was implemented on Feb. 1, 2017.

According to the NGS FAQ, “New to examiner” created a problem with same-specialty groups, where providers in the group are considered by the Centers for Medicare & Medicaid Services (CMS) to be one entity — a concept that applies to both inpatient and outpatient settings. Because all the providers in a same-specialty group are the equivalent of a single entity, if a patient’s new problem has been addressed by one provider in the group, it cannot be considered new to another provider of the same specialty in the same group. NGS reasons that when the first provider sees the patient for the problem, they will have documented the problem, diagnosis, and plan of care, which will be available to all other providers in the practice.

Multi-specialty Practices

Let’s extend this to a multi-specialty practice. Since NGS only means to apply this “new to patient” concept to same-specialty groups, when a provider of a single specialty sees a patient for a new problem treated previously by another specialty in the same multi-specialty group practice, it is considered a new problem. It would be clearer if NGS indicated that the new problem was to the patient or examiner of a different .

NGS is applying the “new problem” versus “established problem” rule for medical decision making in a similar manner in which CMS applies “new patient’ versus “established patient” within a multi-specialty group. Keep in mind that an established patient can have a new problem per these rules.

Also remember that emergency department (ED) providers always see new problems. There is no new versus established patient concept in the ED, so all patient problems in the ED are considered new problems.

Audit forms from Novitas, First Coast and Palmetto (compatible only with Explorer) were reviewed confirmed the continued use of “new to examiner,” at this point. Palmetto, WPS, and CGS do not publish E/M score sheets or E/M worksheets.

Evaluation and Management – CEMC

Practices should be consistent in their application of new versus established problems and be able to support their reasoning should they get audited by one of these carriers.

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.
Barbara Cobuzzi

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Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

2 Responses to “MDM – New Problem to Examiner or Patient?”

  1. Angela Jordan says:

    At one point in time WPS GHA did release their audit tool, but then pulled it back. It was titled “EVALUATION AND MANAGEMENT (E/M) CODING GUIDE” and the date on the document was March 2012. It states under “Category of Problems / Major New Symptoms” for the calculation that, “New problem (to examining physician); additional workup planned, * additional workup does not include referring patient to another physician for future care.” In the E/M webinar series they held last year, they still stated that conditions were new to the provider.

  2. Ellen Hitchcock, CPC,CCP, CMCS,CEMA, QMC says:

    That is funny that this is coming up as I took the CPMA examination and asked the AAPC about this very same issue. I live on the East Coast and we follow NGS which has to the patient . I asked the AAPC and the answer was us your audit sheet with what you are used to. So this would not be correct if all other MACs are not using to the patient .

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