Wiki Diagnosis Management Points Calculation - Est Problem,New Provider (same practice)

[mickeyp23]

Please let me know how many diagnosis management points you would assign????????

Scenario:
An established patient to a single-specialty practice comes in for a second office visit to be seen for the same illness he was seen for 1 week ago by Dr. Smith. However, this time he is seeing Dr. Jones.

Question:

Is Dr. Jones credited 3 or 4 diagnosis management points since it is technically a "new problem to the examiner", or, is Dr. Jones credited 1 or 2 points since it is an "established problem to the practice?"

If anyone can provide a link to anywhere that Mediare gives specific instructions that would be VERY helpful. Thanks!

 

[thomas7331]

Standard practice across most payers I've worked with is to consider two providers of the same specialty in the same group as effectively the same provider, so I would consider this problem as established for purposes of determining the MDM level. Even though most published audit guidelines do not specifically address your situation above, providers within a group and specialty are expected to cover each other in many situations and I think it would be very risky to code your E&Ms higher for that. There are situations, such as for a hospitalized patient, where a different provider might see the same patient each day as they recovered, and if you coded the levels as if it was new problem each time, it would definitely attract the attention of the payers' auditors.

The 1995 documentation guidelines actually say "decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem" and make no mention about the problem being new or established relative "to the examiner". I think that may have been something that was added during the development of some of the audit tools. The original guidelines make more sense in some ways because much of the MDM of a new problem involves making the diagnosis. Once the diagnosis is established, even if changing to another provider, the problem does not have to be diagnosed again and is less complex than if a patient is presenting with something that has never been diagnosed before.