New problem to the examiner

acward

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We are a group of family practice clinics with a shared EMR. A patient came in to one of our clinics to see Dr. A for a UTI. Five days later Dr. B from the same clinic saw the patient in follow-up for the UTI. I'm trying to code for the follow-up visit with Dr. B. Under “Number of diagnoses or treatment options”, would this be considered a new problem to the examiner because Dr. A and Dr. B are different people (and Dr. B has never seen the patient before) or is it an established problem to the examiner because Drs. A and B are both providers from the same group with the same specialty with a shared medical record?
 

KDoerfler

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Kate CPC

On page 1 of E/M guidelines in your CPT book, "an established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years".
 

pamtienter

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We audit those as a new problem to the examiner even if their partner of the same specialty saw the patient for the problem.
 

efrohna

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We audit those as a new problem to the examiner even if their partner of the same specialty saw the patient for the problem.
I agree with Pam on this one. This is in regards to Medical Decision Making, not the 3 year rule with an established vs. new patient.

A new problem would be to the "examining physician", no add'l workup - 3 pts.

A new problem to the "examining physician", additional workup planned - 4 pts.
Hope this helps....
 

LLovett

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I agree with Pam. A new problem is new to the provider, not the patient or the practice.

Laura, CPC
 

terridiaz

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It maybe a new problem to Dr. B, but its actually for a follow up visit already being treated by Dr. A who practices at the same clinic. So you would still have to bill with an established patient e/m, wouldn't you because Dr. A already diagnosised her with the UTI?
 
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pamtienter

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Yes, it would be an established patient E/M but for the "Number of Diagnosis and Management Options" portion of the Medical Decision Making, it would be considered a 'new problem'.
 

Love Coding!

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Hi Acward,

I work for a dermatology practice with 4 PA's and 4 dermatologists. If a new patient is seen by one of our providers and then see's another for a follow-up, that second provider will be billed as an established patient visit. I never heard of a new patient maintaining new patient status when seeing another for a follow up. Can anyone give me some insight on this? Is this implemented by Medicare guidelines?

Thanks!

dscoder74
 

RebeccaWoodward*

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This has nothing to do with the 3yr rule...New v/s Est. We are referring to the medical decision making that is credited to a provider to build the level of his E/M code. As auditors, this is one, very important area for us when we review charts for medical necessity and documentation. The link I provided earlier, gives a decent explanation.
 

Love Coding!

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This has nothing to do with the 3yr rule...New v/s Est. We are referring to the medical decision making that is credited to a provider to build the level of his E/M code. As auditors, this is one, very important area for us when we review charts for medical necessity and documentation. The link I provided earlier, gives a decent explanation.
Apart from the 3 yr rule... Just to clairify, a patient that we have "never" seen in this office before schedules a "new patient" appointment with one of our providers. Then returns to the office, let's say two months later for a follow up for the same problem and sees a different provider in our office. Would it be accurate to say that this follow up would be an established patient visit with a different provider? All of our providers practice under one roof, one building. So in this case for MDM this would be a "1" or "2" (Number of diagnosis or Treatment Options under the table of risk) for an established pt visit if the condition is stable or worsening...

Thank you,

dscoder74
 

Allison L. Wickham

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Allison Wickham, CPC, CPC-E/M

If I were auditing this scenario I would consider to problem to be established.
Here's a question asked and the answer from an Ohio Medicare provider, PalmettoGBA.com

Question -
Must a condition be "new" to the patient or "new" to the provider in order for it to be consider a "new problem" when determining diagnosis/management options for scoring an E/M?

Answer:
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 the patients 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.

This is the rule auditors in Ohio follow when scoring an established vs new problem.
 

RebeccaWoodward*

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Apart from the 3 yr rule... Just to clairify, a patient that we have "never" seen in this office before schedules a "new patient" appointment with one of our providers. Then returns to the office, let's say two months later for a follow up for the same problem and sees a different provider in our office. Would it be accurate to say that this follow up would be an established patient visit with a different provider? All of our providers practice under one roof, one building. So in this case for MDM this would be a "1" or "2" (Number of diagnosis or Treatment Options under the table of risk) for an established pt visit if the condition is stable or worsening...

Thank you,

dscoder74
Assuming that the different provider is of the same specialty, the visit would be established. Personally speaking, if the patient had to see a different provider and this provider was seeing this patient for the condition for the first time, I would probably credit the physician with...
New problem, with no additional work-up planned
OR)
New problem, with additional work-up planned

They are not familiar with the patient's condition; therefore, this allows the physician to receive credit for the complexity of the thought process. This idiology is the Marshfield's Clinic Audit. If you have any audit forms from CMS, their audit forms allow for this. I have, personally, asked our Medicare carrier and they do allow credit for this. This link also provides some good information regarding MDM.

http://www.aafp.org/fpm/980900fm/coding.html

For the record...I am aware of Palmetto's guideline. Our carrier does not follow this guideline; therefore, we are within the guidelines to practice this method.
 
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Allison L. Wickham

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Allison Wickham

The only problem with this format of answering questions is the answers can vary from state to state. As you can see we have 2 correct answers that are completely different. Because we are quoting the medicare carriers from two different states. My piont is you can not always count on the answers you are receiving to be correct. You must research the carriers you are dealing with.
 

RebeccaWoodward*

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I agree Allison. But, I must say; I don't find the majority of states follow Palmetto's standard; just the complete opposite. I am on many other forums and on these forums are individuals spread across the United States. This topic has come up more than once on these forums and the majority of these seasoned coders and their Medicare carrier allow the Marshfields Clinic auditing method. As far as using this platform for coding issues and discussion...many coding issues will be carrier driven. This is why many coders struggle with the day to day issues. What they are taught isn't what is necessarily billable/payable. I utilize this forum to give me direction when I am uncertain about a issue;take it from there and begin my own research.
 
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Allison L. Wickham

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Allison Wickham

Thank you.

The question and answer that I shared was published on the Palmetto web-site in January of 2008. I enjoy reading the threads but I would not change my auditing based on the answers.
 
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its not new problem

i dont agree to the answer that when a pt is seen by dr. a and follow up with dr. b for the same problem in same specialty that it is a new problem to dr. b. the fact that they are in the same specialty assumingly sharing same chart that it would be considered new to dr. b.first time meeting probably but not new problem. And its not a reason to say they are not familiar with the pt's condition because they are sharing the same chart. that is why dr's need to have the pt's chart before they see the pt. Why would you say new when it is already diagnosed and documented in the pt's chart(that dr's are reading before seeing the pt).:confused: :eek:
 

JenniferCalma

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It should be EST to prov B

i dont agree to the answer that when a pt is seen by dr. a and follow up with dr. b for the same problem in same specialty that it is a new problem to dr. b. the fact that they are in the same specialty assumingly sharing same chart that it would be considered new to dr. b.first time meeting probably but not new problem. And its not a reason to say they are not familiar with the pt's condition because they are sharing the same chart. that is why dr's need to have the pt's chart before they see the pt. Why would you say new when it is already diagnosed and documented in the pt's chart(that dr's are reading before seeing the pt).:confused: :eek:
I have to agree with Mr. Laurente. The patient was seen by providers of the same specialty. Prov A already coded the diagnosis and patient was seen by prov b for teh same problem - should have been coded as EST not new. The problem is already pre-existing condition and was previously diagnosed by a provder of the same specialty. Thank you.
 

RebeccaWoodward*

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Well...I can certainly understand your apprehension since everything in the coding world is not finite. I have emailed Dr Jensen; creator of E/M University for clarification but most importantly, I am emailing our Medicare carrier for clarification so that I have written confirmation; although, I have already received verbal confirmation. I am curious though; for those of you that perform chart reviews, when do you credit the provider with a new problem? Also, let's assume that the patient leaves once practice and relocates to an entirely different group and records are transfered...would you not credit this physician with a new problem?
 
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Let's be clear ....

The question here is NOT about whether to code 99201-99205 (New Patient Visit) Vs. 99211-99215 (established patient visit. We are all in agreement that this second visit to the office is an established patient visit.

The question here is whether, when counting the problem points for determining medical decision making, the problem is a NEW problem to Dr B, who has not previously seen this patient for this problem.

I would credit this as a new problem to Dr B. Even with a shared medical record, Dr B must still come at this without any personal history of evaluating this patient's problem previously. If the two physicians were not in the same practice, even though the problem had already been diagnosed and treatment started, you'd still give Dr B the "new problem" points. (So, Rebecca, to answer your last question about a transfer to a new practice, Yes, I'd give credit in MDM for a new problem.)

F Tessa Bartels, CPC, CPC-E/M
 

RebeccaWoodward*

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Tessa,

Thank you..... I value your opinion and was waiting to hear from you or someone with your background. I know this topic is not easy for some to digest but you really have to look at the big picture and all the components involved. You must have known what I was thinking when I posted my last question and you nailed it by stating...

"If the two physicians were not in the same practice, even though the problem had already been diagnosed and treatment started, you'd still give Dr B the "new problem" points"

That was the point I was trying to "drive home" but I was waiting for someone to open up the dialogue.

Thanks again~
 

Love Coding!

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For Tessa :0)

Hi Tessa,

If you are out there, I'm sorry I'm one of those that needs additional digesting :0).

So you have an established patient that comes in for a follow up lets say for psoriasis and saw provider A a month ago and they come back and see provider B for the same problem for a follow up to this "problem" would this be considered a "new problem" to provider B? Does it need to be documented by provider B that this is a "new problem" to them? Does this differ in each state? I am from Arizona.

Many thanks in advance,

dscoder74
 
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I sent you a private message

I really don't want to be getting into the nitty gritty of dissecting everyone's E/M notes.

Use your judgement. In my experience most doctors do give you some clue as to whether they've seen this patient for this problem previously. If they haven't I give them credit for a new problem (unless it's "self-limited or minor")

Okay, I'm done answering this question ...

F Tessa Bartels, CPC, CPC-E/M
 

Amanda.Kane

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I, too, agree...

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. (Do not get this confused with the 3 year rule..New versus Est. patient)

http://emuniversity.com/MedicalDecision-Making.html
Thanks Rebecca! I was trying to find a resource to help in a debate with a co-worker about this. Your link is very helpful!

-Amanda
 
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