Wiki Can a problem become new again?

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csperoni

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Is there a timeframe for a problem to be counted as a new problem again (regarding medical decision making)? Is it the same as new patient - > 3 years?
Scenario: Patient seen 2015 for pagets disease. Failed to follow up, and now returning in 2020 with same symptoms/issue. The visit is definitely new since > 3 years. The question for me is whether I can count the problem as new. I couldn't find a reference stating it could, only the multiple references regarding coding the patient as new. I am inferring that if the patient is considered new, then so should the problem. Any input is appreciated!
 
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From that first link, I was looking at this part: problem that are new to the patient or that the physician is seeing in this patient for the first time

I would argue that if the patient has not been seen in three years, and they have therefore reset to the status of "new patient", then they fit the "that the physician is seeing in this patient for the first time" would apply and it would be considered a new problem. I think I would agree that any problem is a new problem, and that everything resets to new.
 
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Is the patient seeing the same provider? I didn't know this until last week after watching an E/M University webinar that if a patient sees a provider in your office that they haven't seen before that any problem that the patient might have would be considered new to that provider even though it's not new for the patient.
 
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SharonCollachi said:
This is a bit of an old thread from this site, but it addresses pretty much the same issue.

This one sort of addresses it.
Click to expand...
Thanks for the input, but perhaps my original question was not 100% clear.
The first link is asking about a new provider seeing a patient for an existing medical condition, whether that is a new or established problem. The answer is yes, but that is not my question.
The second link seems to ask the same question I am, but does not give an answer. The OP states she counted it as established problem, but was told she was incorrect, it is a new problem. The people answering are all discussing whether the visit is new or established. I know the visit is new. The question is whether I can consider the PROBLEM new if the same provider has not seen the patient in years.

More detailed example:
Diabetic sees endocrinologist in NY for years. Patient moves to FL and sees a different endocrinologist. Patient moves back to NY and goes back to the initial endocrinologist 10 years later. Assume hx & exam is comprehensive. Assume no other problems, no records reviewed, labwork is ordered, 2 rx written.
It is clearly a new patient E/M. For medical decision making, is the DM considered a new problem or an established problem? Does the problem have a "reset to new" after 3 years, like the E/M does?
If I count the problem as new since the provider has not seen the patient in 10 years, I wind up with 99204. If I consider the problem established, I wind up with 99202.

I am thinking - how could you see a new patient for an established problem? However, technically it is not a new problem to the provider, UNLESS the definition of new problem resets after 3 years, like the definition of new patient does. I could not find any reference stating one way or the other, only about whether the patient is new or established.

Any discussion or opinions are appreciated!
 
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SharonCollachi said:
From that first link, I was looking at this part: problem that are new to the patient or that the physician is seeing in this patient for the first time

I would argue that if the patient has not been seen in three years, and they have therefore reset to the status of "new patient", then they fit the "that the physician is seeing in this patient for the first time" would apply and it would be considered a new problem. I think I would agree that any problem is a new problem, and that everything resets to new.
Click to expand...
Thank you Sharon. That was my logic - how could it possibly be an established problem if the patient is considered new, but I could not find anything to definitively support that. The millions of references I found were all for defining new patient, which I already knew.
The argument against (not my opinion, but could be argued) is that you have treated the problem before, and there is nothing I could find defining that new problem means not treated by provider in > 3 years.
Certainly not something that comes up often, and I will consider new problem definition same as new patient definition unless someone can point me in the other direction.
 
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I have never seen any definitive guidance on a time frame for when a problem can be considered new or established. However, I can tell you that the Medicare Contractor in the region where I work (NGS) at one point revised their E&M audit tool to change the wording in this section, which originally specified that a new problem was new 'to the examiner' but now states new 'to patient'.

This suggests to me that they consider it to be new not if it is just new to the particular provider who is evaluating it, but new to the patient - in other words, a new diagnosis altogether. This also seems to line up with the wording in the 1995 official guidelines which state that "decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem" but which make no mention of decision making being more complex if new to a particular provider. I tend to agree with this interpretation, because even if new to a provider, decision making will be simpler if there is a clear record of the patient's past testing and responses to treatment versus what would be required if the provider is evaluating or ordering treatments for a completely new problem for which the patient has no history to refer to.

So I guess my answer to the original question would be no, a problem cannot become new again, if the record shows that there is a clear history that was available to the provider at the time of the encounter.

Either way, as I always advise my coders, MDM is always a grey area subject to interpretation and the guidelines are just that - a general guide and not a fixed rule that will apply in every situation. The level of complexity of decision making in every encounter will be unique, and no audit tool can perfectly classify every situation in a way that every coder or auditor who looks at the record will agree. There will always be an element of judgment in this area, but as long as you are able to point out the elements of the documentation that support why the encounter should be considered of higher complexity, then that's about the best any of us can do.
 
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thomas7331 said:
decision making will be simpler if there is a clear record of the patient's past testing and responses to treatment versus what would be required if the provider is evaluating or ordering treatments for a completely new problem for which the patient has no history to refer to.
Click to expand...

What you say makes a lot of sense. This part stuck out to me; often our patients do NOT have a clear record of treatment/testing. We dig back thru records and it is never nailed down as to who/when it was diagnosed. Conditions like lupus, fibromyalgia, complex regional pain syndrome - things that no one single test exists to diagnose. I know it would be different for every specialty, but in ours, I am always skeptical because so many people like to self-diagnose with google.
 
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