Wiki New problem or established problem?

[cdcpc]

Here's a question for all you auditors out there:
I have a patient that came in November and she was diagnosed with bilateral hand parasthesia. She was sent for a nerve conduction study and came back in December for the results. At the December visit, she was diagnosed with bilateral hand neuropathy and Raynaud's syndrome.
Clearly, the two visits are dealing with the same problem, however the problem is being called by a more specific name. Should I classify the December diagnoses (bilat hand neruopathy and Raynaud's syndrome) as new problems or established problems

 

[pamtienter]

Is she coming back to see the same provider? If so, since it is the same "issue", although now given a diagnosis, I would consider it an established problem.

 

[FTessaBartels]

Established problem

The problem is the same. The diagnosis is just more definitive.

F Tessa Bartels, CPC, CEMC

 

[cdcpc]

Yes--same physician

Is she coming back to see the same provider? If so, since it is the same "issue", although now given a diagnosis, I would consider it an established problem.

Pam,
Yes-the patient is coming back to see the same physician. Sorry I forgot to mention that!