Wiki New diagnosis vs Established diagnosis

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TiffanyM101

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How do you know when the dx is new/established? If the pt is new to us then the dx is new? Or is it considered established if they have had the condition prior to seeing us? Thanks for your help in advance.
 
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xXxPARAGONxXx said:
Send an ROI to the patient's previous provider to request the clinical documentation. Once received, your provider reviews the clinical documentation and determines if the patient was properly diagnosed. If so, then the provider can confirm the diagnosis. This is why clinical documentation is requested from previous providers for continuity of care.

A patient's testimony about a diagnosis is not sufficient to confirm a diagnosis. The provider can note in their visit note that “patient reports”, but the provider knows they must confirm the diagnosis either their self by performing the requisite diagnostic tests, etc. or by reviewing clinical documentation from another licensed provider who has already performed the requisite diagnostic tests, etc. The latter is certainly preferred.

So, to answer your question, until your provider has confirmed the diagnosis as discussed above, the condition should not be coded.
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This didnt answer my question! I know that if there is no confirmed dx you cannot code.

IF the pt has had a condition for years and then is referred to us and its our first time seeing the pt - is that condition considered established or new?
 
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TiffanyM101 said:
How do you know when the dx is new/established? If the pt is new to us then the dx is new? Or is it considered established if they have had the condition prior to seeing us? Thanks for your help in advance.
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I would ask why you are trying to determine if the diagnosis is new/established. For the current leveling of complexity of problems addressed, rather than new/established, it is about whether the problem is acute or chronic. The only situation where new comes into play is undiagnosed new problem with uncertain prognosis. Sometimes explaining why you are trying to determine something can help others guide you.
 
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TiffanyM101 said:
How do you know when the dx is new/established? If the pt is new to us then the dx is new? Or is it considered established if they have had the condition prior to seeing us? Thanks for your help in advance.
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I think @Cheezum51 addressed your question (if indeed this was what your question pertained to) in his post on this thread, when he wrote,

Cheezum51 said:
One other point. If the patient was diagnosed with a problem by another provider and they switched medical practices and doctors, those problems diagnosed by the prior doctor are "new" to the new provider. They would have to confirm that the prior diagnosis and treatment are correct by discussing things with the patient and evaluating test results etc. An example might be something like a patient who has been diagnosed and treated by doctor A but decides to change to Doctor B for some reason. That's a new patient with a new diagnosis, at least for Doctor B, who would now determine if the patient's treatment is working properly and perhaps even change treatment. Maybe the patient wasn't happy with treatment by Doctor A due to medication or disease side effects the patient didn't feel were being addressed properly, so they decided to change to Doctor B. IMHO Doctor B should be able to get MDM credit for both dealing with the, to them, "new" diagnosis and its subsequent treatment.

Tom Cheezum, OD, CPC, COPC
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And yet, Noridian wrote the following, here,

Q10. The patient's problem is new to me. Can I use the moderate level "undiagnosed new problem"?
A10. The complete AMA problem definition is "undiagnosed new problem with uncertain prognosis." This is a new problem to the patient not the practitioner. If the patient was aware of the diagnosis before the specific encounter, this is not a new problem. In addition, the AMA definition is "A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast." Documentation must support the new diagnosis and how the problem would likely result in a high risk of morbidity without treatment. A patient may have a new problem that could fall into one of the other categories such as a sinus infection.
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I think using the words new/established can be confusing because those are the words used to describe the patient in relation to the provider they are seeing. This wording does not relate to COPA.

Using the words "problem, illness, injury and acute or chronic" is better when referring to COPA. As mentioned by @csperoni, there is no wording when it comes to the Number and Complexity of Problems Addressed which refers to the problems using the words new or established. The only reference to new is when it is an, "1 undiagnosed new problem with uncertain prognosis."
If a patient is a new patient to the provider, it doesn't necessarily mean their presenting problem is. You need to separate the fact that the patient is new/established from trying to determine the COPA. It really doesn't impact the COPA whether they are new or established patient. An established patient can come in to their provider with a problem they have never had diagnosed before, it is dependent upon if it is acute or chronic. However, a new patient "might" have a higher level E/M if there was more workup required, reviewing outside records, consulting with outside providers, ordering more tests, etc.

Read the definitions of the COPA items in the CPT book in the E/M Guidelines in the front. For example, the definition of: Undiagnosed new problem with uncertain prognosis - A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. The key words here are: high risk of morbidity without treatment. Just as the Noridian quote above states.

It is always going to come back to the documentation. Throw out the fact that the patient is new or established and look at the documentation in relation to the E/M definitions and MDM table (unless you are coding by time of course).

This link gives an example of something that may meet the undiagnosed new problem with uncertain prognosis: https://www.bcarev.com/2021/04/01/undiagnosed-new-problem/

In relation to your question: "IF the pt has had a condition for years and then is referred to us and its our first time seeing the pt. - is that condition considered established or new?"
The answer is, it depends. If the patient has had a known condition for many years, and they are a new patient, it doesn't mean the diagnosis is an undiagnosed new problem with uncertain prognosis. It could be 1 or more chronic illnesses with exacerbation, 2 or more stable chronic, 1 or more with severe exacerbation, or possibly 1 stable chronic. It depends on the documentation and what is done. Do you have an example we can help you with specifically?
For example, a patient with Type 1 diabetes moves to a new city, they have had this since birth, they go in for a new patient appointment with a new provider, the condition is being managed by their current CGM and insulin pump, and rx. meds and it is stable. The patient has no other issues. This is not a new problem even though the patient is new to the provider. The provider keeps the patient on the same course and has them f/u in one month. This is a stable, chronic (Low COPA). The provider ordered and reviewed 3 unique labs and reviewed the notes the patient brought from their old provider (Moderate Data), there are prescriptions refilled and managed (Moderate Risk). This would be a new patient Moderate MDM 99204 even though COPA was low.
 
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