Question Undiagnosed new problem with uncertain prognosis?


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Undiagnosed new problem with uncertain prognosis: When does a problem go from being new to chronic? For example, patient has an elevated PSA at their new patient appointment (new problem), some tests are ordered, then they follow up in one month. Could we use "undiagnosed new problem" again since we are still trying to diagnose and figure out what's going on? Or is it no longer a new problem because we have seen the patient before?
Here's the full definition:

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.
I think this is another instance where the coder needs the treating provider's input. It also creates an opportunity to tell providers what they need to document so coders can process their claims and they can get money.

At any rate, if the physician's response to the test results is "come back next month" that could be a sign they don't view the problem as that urgent. But again, the AMA designed the new E/M guidelines to defer to the provider's judgement.
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