Wiki Need help with number of Diagnoses/ Treatment options

[maryberg11]

I am being told that only 1 diagnosis and or treatment option can be used for a new patient encounter, but
you can have more for an established patient. So, if a new patient has 2 issues, you only count the more severe one.
Does this sound correct to anyone? This would be initial physician encounters in patient's homes, ALFs, and skilled nursing facilities.

Thank you in advance for your help.

 

[Cheezum51]

I would disagree with that. It depends on the number of problems a provider addresses during the exam. If a new patient had both hypertension and diabetes, why not address them both, and be paid appropriately, if desired.
Doing that for a new patient would be 2 "new" problems for the doctor to address, since they hadn't seen the patient before, and that automatically brings the visit up to at least a level 4 E/M

Tom Cheezum, OD, CPC, COPC

 

[maryberg11]

I would disagree with that. It depends on the number of problems a provider addresses during the exam. If a new patient had both hypertension and diabetes, why not address them both, and be paid appropriately, if desired.
Doing that for a new patient would be 2 "new" problems for the doctor to address, since they hadn't seen the patient before, and that automatically brings the visit up to at least a level 4 E/M

Tom Cheezum, OD, CPC, COPC

I really appreciate your help. Let me take this a step further. I am referring to hospice patients. I'm still very new at this, but this is where it gets blurry for me. If the physician is treating multiple symptoms, are they each counted as a management option? So if a patient is being treated for delirium, pain, dyspnea, and edema, do each of these items count as a separate management option? Thanks!