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est. verses new problem

  1. #1
    Location
    Duluth, MN
    Posts
    14
    Default est. verses new problem
    Medical Coding Books
    We had a patient be seen for knee pain and an MRI was ordered. Now patient is back to see MD to discuss MRI results and was diagnosis with a torn meniscus. Would the torn meniscus be considered a new problem with workup (pt referred to ortho) or would it be considered established problem based off the first visit of knee pain?

  2. #2
    Location
    Murfreesboro, TN
    Posts
    38
    Default New vs. Established
    The criteria for new vs. established patients is that if the patient has seen this provider, or another provider in the same practice with the same specialty and the same subspecialty, within the last three years, then the patient is "established".
    But I think you might be asking about assigning points for the levels of the encounter, with regard to new problems vs. old problems. In the case you mentioned, this would not be a new problem to the physician since they were already seen for the knee pain. Now we know a true diagnosis for it but it is still the same problem.
    I hope that helps!

  3. #3
    Location
    Duluth, MN
    Posts
    14
    Default
    Yes, that is what I am asking...about the diagnosis/point scale. That is what we told Provider as well (that it would be established problem) but she is not agreeing so wanted a second opinion. Appreciate your response!

  4. #4
    Location
    Austin, Texas
    Posts
    467
    Default
    Quote Originally Posted by Kristene View Post
    Yes, that is what I am asking...about the diagnosis/point scale. That is what we told Provider as well (that it would be established problem) but she is not agreeing so wanted a second opinion. Appreciate your response!
    You have an established problem with a now definitive diagnosis based on the MRI. The MRI should have been medically necessary due to ongoing pain complaints with signs and symptoms with objective clinical documentation that were not resolving with conservative care. Your doctor should have documented those signs and symptoms and the conservative care measures.
    Marcus Murphy, CPPM

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