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A patient was treated for a cold in November. The patient was diagnosed with acute sinusitis. Four weeks later (in December), the patient comes back to see the same physician with the same symptoms. The December documentation states "had sinusitis 4 weeks ago, but it got better and then developed symptoms again" She is again diagnosed with acute sinusitis.
Technically, she is being treated for the same diagnosis as her November visit, but should the December visit diagnosis be considered a new problem because it's a new onset of an acute problem?
I'm leaning more towards new problem, but I wanted to see what others thought.
If you have any reliable literature regarding this issue, please send that along with your feedback.
Thanks :)
 
Established problem

I agree with Rebecca ... because the physician specifically cites the previous visit and "interval history" I'd consider it an established problem.

F Tessa Bartels, CPC, CEMC
 
I would give credit for new since they are calling it acute not chronic.


Laura, CPC
 
I agree with established problem. Doesn't seem like it ever resolved.. "got better but symptoms came back" Maybe if it was a year later or something, then I'd call it new.

Just my 2 cents worth!:)
 
Thanks

Thanks to everyone for the responses. It helps so much to get feedback from colleagues, especially for grey areas like this one.
After reviewing what everyone has said, I've changed my opinion because I now feel there is more evidence to prove it as an established problem.
 
This is an established problem they are coming back for and should use the V67.59 code for a follow up visit that is on going. If it started as a cold and now it's sinusitis it's still the same problem it just got worse from the last visit.
 
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