Need some help guys...

ARCPC9491

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I'm trying to prove (how does that happen, they're always right;)) to a physician that a "new problem" is new to the "provider" regardless if they have seen another physician in the practice with the same issue... does anyone have something in writing that they would like to share so I can get her off my case? I can't seem to find anything and I've never been asked to prove this..in writing..
 

Anna Weaver

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new problem

I'm trying to prove (how does that happen, they're always right;)) to a physician that a "new problem" is new to the "provider" regardless if they have seen another physician in the practice with the same issue... does anyone have something in writing that they would like to share so I can get her off my case? I can't seem to find anything and I've never been asked to prove this..in writing..
Found this on e/m university:
E/M University Coding Tip: Problems are defined relative to the examiner, not the patient. Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.

Hope this helps!
 

RebeccaWoodward*

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South Carolina Part B Carrier (Palmetto)
Must a condition be “new” to the patient or “new” to the provider in order for it to be considered a “new problem” when determining diagnosis/management options for scoring an E/M?

The term "new problem" is one that is identified yet undiagnosed and may or may not require an additional work-up. A patient presenting to a new provider with a diagnosed problem is scored the same as presentation to a provider familiar with that patient's problem. Therefore, for the purpose of scoring E/M documentation, a new problem is one that is new to the patient, not to the provider

AR,

My current contractor does allow the physician to receive credit for a new patient problem. HOWEVER, Palmetto was awarded the contract for our region. This is being protested and the final decision should be made around
5-13-09. So...as you can see, this will be unsettling for my providers
 

ARCPC9491

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Interesting... that's so discrediting to the physicians. I hope it gets overturned. My current contractor,Trailblazer, is switching to Palmetto...:rolleyes:
 

RebeccaWoodward*

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You're kidding?? So, you'll be in the same predicament as us. I can tell you now...I will have some physicians in an uproar. I haven't begun to look at any other changes that Palmetto will impose. I would hate to do all that leg work to only find out that the contract was overturned. On the other hand...I want to be prepared, also. What to do???:confused:
 
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Provider vs patient

Where is Palmetto coming from? The whole purpose of the MDM is to try to find a way to quantify the physician's thought process.

Even if I've had a belly ache for the last six months and seen three other physicians, it's still a new problem for THIS doctor. S/He still has to go through the thinking process to qualify the problem, seek out the cause, decide on the need for additional work-up, plan a course of treatment, etc.

With Palmetto's guideline there is no way a consultant will EVER get to a high level of MDM unless s/he orders a lot of tests to get the data points.

The carriers just keep trying to find more and more reasons to NOT pay us! (So their CEOs can get their multi-million dollar year-end bonuses.)

Sheesh. I need some chocolate ... LOTS of chocolate!

F Tessa Bartels, CPC, CEMC
 

RebeccaWoodward*

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I completely agree, Tessa! If and when this marriage happens, I'm sure there will be alot of hair pulling and nail biting. So...I've started looking around their website for clarification.

Q-How do you determine that a problem is a new problem or if it just an exacerbation of an established problem?

For example: a patient had gastric esophageal reflux disease (GERD) and the patient is experiencing heartburn, nausea, and vomiting. Is this a new problem of nausea and vomiting or is it simply a symptom of GERD which is worsening?

A- Documentation is key in this scenario. The physicians/nonphysician-practitioner’s (NPP) documentation must support whether it is a new problem of heartburn, nausea, and vomiting or whether it is an exacerbation of GERD. The medical record should reflect a clear picture of the physician’s/NPP’s view as to if it is a new problem or not.

So...I guess our surgeons/providers will have to become creative with their documentation while still being compliant.
 

aguelfi

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So how does all of this work when seeing the patient for the first time if it's a self limiting problem but it's new? Which one do you choose minimum or multiple? it's new for both
 
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