Pediatric Coding Alert

Question: When is a problem a new problem?

Example: A patient is seen in the emergency department (ED) for abdominal pain that got worse. The ED physician found nothing. A pediatrician sees the patient two days later for persistence. In regards to medical decision making complexity, should I consider the problem new or established?

Pennsylvania Subscriber

Answer: When determining a problem's status using the CMS standard documentation worksheet (available at www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf), consider the problem new when it is new to the examiner.

Provided the problem is not self-limited or minor (stable, improved, or worsening), the sheet assigns more points to a new problem than to an established problem. The increased values account for the added work involved in the physician making the differential diagnoses and weighing the treatment options as part of medical decision making's "Number of Diagnoses or Management Options." "Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiag-nosed problem," according to the 1995 E/M guidelines.

In your case, the pediatrician has not previously treated the patient for abdominal pain. A stomachache that is not improving and required a trip to the ED and two office visits is certainly not a minor problem. Therefore, you should consider the problem as "new."

Presumably the physician in your case would decide that the new-to-him clinical issue of stomachache would require further investigation. For a new problem with additional work-up planned, you would give 4 points under MDM's "Number of Diagnoses or Management Options," consistent with a highly complex level of medical decision making. If the physician planned no additional work-up, you would assign three points consistent with moderate complex medical decision making.

Suppose, however, that the pediatrician had first seen the patient for abdominal pain before she presented to the ED. After continued pain, she then returns to the pediatrician again.

For the second visit to the pediatrician for abdominal pain, you would consider the problem as "established." The physician was already familiar with the problem and had gone through the initial rule-outs, etc. Because the problem is worsening, you would assign two points under MDM's "Number of Diagnoses or Management Options" consistent with low complexity MDM. If the established problem was instead stable or improving, you would give 1 point for the problem's status.