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New problem or established problem?

  1. #1
    Default New problem or established problem?
    Medical Coding Books
    Here's a question for all you auditors out there:
    I have a patient that came in November and she was diagnosed with bilateral hand parasthesia. She was sent for a nerve conduction study and came back in December for the results. At the December visit, she was diagnosed with bilateral hand neuropathy and Raynaud's syndrome.
    Clearly, the two visits are dealing with the same problem, however the problem is being called by a more specific name. Should I classify the December diagnoses (bilat hand neruopathy and Raynaud's syndrome) as new problems or established problems
    Carrie, BS, CPC

  2. #2
    Default
    Is she coming back to see the same provider? If so, since it is the same "issue", although now given a diagnosis, I would consider it an established problem.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Established problem
    The problem is the same. The diagnosis is just more definitive.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default Yes--same physician
    Quote Originally Posted by bpct6501 View Post
    Is she coming back to see the same provider? If so, since it is the same "issue", although now given a diagnosis, I would consider it an established problem.
    Pam,
    Yes-the patient is coming back to see the same physician. Sorry I forgot to mention that!
    Carrie, BS, CPC

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