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  1. Default Mdm
    Medical Coding Books
    I am new to coding inpatient and I have run across another question. When a patient is treated in the office for an infection and two days later gets admitted because the same infection is now gotten worse would this be counted as a new problem or as an established worsening? And if it is a new problem when the patient is admitted what about the subsequent days would it still be considered a new problem or is it considered established after the first day.

    Thanks for any help.

    Denise Smith CPC-A

  2. #2
    A problem becomes established after the provider has seen the patient for it.

    So in your case, the first outpatient visit it would be new, when they admit the problem is established worsening.

    Same thing on your inpatient scenario, first visit new, every visit after that it is either established stable or worsening.

    Now on the flip side, say this same patient gets better goes home and later on gets another infection and comes back to your provider. Even though he treated an infection before, this would now be a new problem.

    Hope this helps,

    Laura, CPC, CEMC

  3. Default
    Thank You, I thought that was the right way, but I wanted to make sure.

    Denise Smith CPC-A

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