Wiki Established problem but "New" patient since it has been over 3 years

clarkmegan

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If a patient's PCP is referring him back to our office for re-evaluation of a problem treated by us more than 3 years ago, is that worth 2 points (est. problem worsening) or 4 points (new problem, additional workup planned) under # of diagnoses or treatment options in MDM? The patient would be considered "New" since it has been 3 years, but problem is not new to the provider. Thanks.
 
If a patient's PCP is referring him back to our office for re-evaluation of a problem treated by us more than 3 years ago, is that worth 2 points (est. problem worsening) or 4 points (new problem, additional workup planned) under # of diagnoses or treatment options in MDM? The patient would be considered "New" since it has been 3 years, but problem is not new to the provider. Thanks.

The published E&M guidelines do not get down to this level of detail so you will have to make a choice based on your review of the notes. But I would suggest that an outside auditor reviewing your provider's note would likely assess the MDM of the visit based on how it is reflected in the documentation and is not going to be looking at the patient's visit history to figure out exactly how long it was since the patient was last seen. If the documentation reflects that the problem was established and previously evaluated and treated by the provider, then that is how the auditor would classify the diagnosis points.
 
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