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"New" Problem points for problem seen before

  1. #1
    Default "New" Problem points for problem seen before
    Medical Coding Books
    If a patient hasn't been seen in 3 years, the patient is considered "new" for E/M coding. If the patient's problem isn't new to the provider though, is it considered an established problem or a new problem again? For example, a patient was seen 4 yrs ago for epilepsy. The seizures are now more frequent and require a change of meds, for which the neurologist is referring the patient out to an epileptologist for management. Would this be 2pts (est. prob worsening), 3 pts (new problem no w/u) or 4 pts (new problem with w/u for the referral) for the neurologist?
    Sue Vermette, CPC, CPMA

  2. #2
    If the patient has not been seen for 4 years, they would be a new patient again.
    So it should be new problem w/work up.
    Kelly A Mcfadyen, CPC

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