Wiki Does the PROBLEM become new after 3 years??

[nevrolog]

I saw patient more than three years ago for problem A. Seen again for same problem over three years later, so he is a "new" patient. The question is, in the PROBLEM portion of the MDM analysis, do I count this as a NEW or and ESTABLISHED problem? That determination alone can make the visit vary from a 99203 (if an established problem) up to a 99205 (if a new problem).

 

[OCD_coder]

Yes, that would be considered a NEW problem to you. You must collect an interval history that encompasses 3 years, you also may need to order a whole new diagnostic workup which essentially is like the patient has never had the condition before. Oncology runs into this for a patient that has a recurrence of cancer years later, the same workup is going to occur to determine whether the patient has cancer, but also what treatment plan is appropriate. It is unfair to penalize a provider because the patient has had the condition before but it was resolved.

A "problem" is considered NEW to the provider when it can be considered new if the problem has resolved in the past and reoccurs and has not been followed routinely for medication refill or "monitoring".

Examples:
A cancer patient in remission is monitored annually to be sure they remain in remission, established problem.
A patient had pneumonia in January and it resolved with no chronic respiratory problems and documentation states "resolved" on the last follow up. Patient then presents in April with similar symptoms and after workup it is determined that a recurrence of pneumonia is found; New problem.

Some carriers are a little more restrictive in that if a provider without your group sees the patient for the same condition and another provider follows up care, that problem is considered as new. I would agree with this if it were a chronic condition like COPD or a maybe a cardiac condition like hypertension. I can see thought process this if a follow up physician is simple doing the equivalent of a rounding/follow up care and no workup is performed and improving.

But if the second physician is doing an extensive workup because maybe the prior physician didn't specialize in that area, I would stress to the treating provider in their documentation that this was the first encounter with the patient and use the problem as new, because then additional workup elements would take effect in the MDM Diagnosis Options which would give additional support when the nature of the presenting problem is High Risk which may support those 99205's that are so hard to report.

Novitas:
New condition
–By provider: if a patient has been seen by another provider in the department, but it is the first time you have seen the patient, the patient’s conditions are new to you (to the examiner)

 

[MarcusM]

New patient is not a "new problem". Patient can have a life long medical condition, and your doctor used to treat for this condition. If three complete years have gone by, the patient is a "new" patient with an established medical condition because a lot can change in three years. But his condition clearly has changed in some form, otherwise why is he coming to you for treatment?
Likewise an established patient can come to your doctor and mention a new problem, not previously ever mentioned, fell and cut knee. This is not a new patient eval, but established with CPT code as established, but may be a higher level due to new presenting problem.