mhstrauss
True Blue
Hey guys and gals, need some help from y'all again please 
Patient comes in for initial eval for low back pain with our neurosurgeon. Since this is the patient's first visit with us, the low back pain is obviously a New Problem under Number of Diagnoses. There is no previous imaging, so we can only code the symptom (pain) at this point. Doc orders an MRI. When patient comes in for follow up to discuss MRI results and treatment options, we now know that he/she has a herniated disc. For this followup visit, under Number of Diagnoses, should the Herniated disc be considered a new problem since we didn't have a definitive diagnosis prior? I've always considered this to be an established problem in this situation, since it's still “low back” issue, but in an education session with one of my providers recently, the point was brought up that it would be a New Problem since this is the first visit they have a true diagnosis. Would appreciate any ideas/feedback. Thanks!!
Patient comes in for initial eval for low back pain with our neurosurgeon. Since this is the patient's first visit with us, the low back pain is obviously a New Problem under Number of Diagnoses. There is no previous imaging, so we can only code the symptom (pain) at this point. Doc orders an MRI. When patient comes in for follow up to discuss MRI results and treatment options, we now know that he/she has a herniated disc. For this followup visit, under Number of Diagnoses, should the Herniated disc be considered a new problem since we didn't have a definitive diagnosis prior? I've always considered this to be an established problem in this situation, since it's still “low back” issue, but in an education session with one of my providers recently, the point was brought up that it would be a New Problem since this is the first visit they have a true diagnosis. Would appreciate any ideas/feedback. Thanks!!