Wiki Diagnosed New Problem

[carriganm]

We often see that a patient comes in for a lab follow-up and the provider dx'd the patient with a new problem. I am trying to figure out how to categorize this in the MDM as it doesn't fall under any of the definitions for number of complexity of problems addressed.

Example:
Patient had labs drawn and came back in to review. After reviewing, practitioner dx'd the patient with Hyperlipidemia & Hyperthyroidism when patient does not have any history of this. Practitioner is going to monitor and recheck lab levels in 1 month. How do I categorize those problems?

Thanks!

 

[csperoni]

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

From the AMA guidelines above, a chronic problem is expected to last at least one year. An acute problem is short-term. Both hyperlipidemia and hyperthyroidism would be considered chronic problems. Even if they have not already existed for a year, it would be expected to last at least a year (more likely for the life of the patient). Unless either problem is SOOOO severe that the provider is considering hospitalization, it generally would not meet high (level 5 for problem). If either problem is rather severe, you might consider one (or both) as a chronic illness with exacerbation, progression or side effects of treatment.
From a practical coding standpoint, whether you consider them 2 chronic stable, or 1 chronic stable and 1 chronic with exacerbation, or 2 chronic with exacerbation, for problems, you are at moderate (level 4 for problem). So I wouldn't sweat exactly how you categorize each one since it will not impact your E/M level.