Wiki Undiagnosed new problem with uncertain prognosis

[lhoot]

Good Morning,
My question has to do with complexity of problem in determining E/M.
Does a final impression/final diagnosis of a symptom constitute an undiagnosed new problem with uncertain prognosis? Example would be patient seen for abdominal pain.

Assume both cases are identical except for the final diagnosis and I’m only referring to the complexity of the problem.
Case 1: Patient with complaint of abdominal pain. Final diagnosis is constipation. I would consider constipation to be an uncomplicated illness.
Case 2: Patient with complaint of abdominal pain. Final diagnosis is abdominal pain without an actual diagnosis. Would this be an undiagnosed new problem with uncertain prognosis, since this is a symptom and not an actual named diagnosis? Is a symptom, like abdominal pain, a minor problem or acute, uncomplicated illness?

I welcome any thoughts or advice.
Thank you,
Laura Hoot RHIT, CCS

 

[thomas7331]

Taken out of the context of a complete note, I don't think it's possible to say one way or another what the complexity of a given diagnosis is. Taking your example in case 2, If I was auditing the note and the only diagnosis was 'abdominal pain', I'd look to see what the treatment plan is and what provider is ordering. For example, if the provider is sending the patient home and recommending OTC antacids or laxatives, then I would say this is being treated as a minor problem. On the other hand, if the provider is sending the patient for an urgent CT or referring them to a specialist, then they're clearly treating the abdominal pain as an undiagnosed problem that could potentially be something more serious. MDM is always specific to the patient and the encounter, and with the exception of a handful of diagnoses that can safely be classified one way or another (e.g. acute MI or stroke), I don't think a coder can ever assume a certain complexity of a condition without referencing the rest of the provider's assessment and treatment recommendations.

 

[lhoot]

Thanks so much, Thomas. Sometimes, hearing an explanation in a different way sheds more light on the subject. So, in determining an undiagnosed new problem, it’s not the actual problem necessarily, but the physician’s response to the problem.

Thank you again,

Laura