AAPC - Back to school
Results 1 to 3 of 3

Thread: New Prob to Examiner - MDM - Documentation

  1. #1
    Join Date
    Apr 2007

    Default New Prob to Examiner - MDM - Documentation

    AAPC: Back to School
    I am trying to find documentation that states an ER visit is considered a new problem to examiner in MDM everytime a patient comes to the ER. I have read where coders have said it but nothing in writing to show the logic of it. Please help!! Thank you.

  2. #2


    I've come across this same situation. Does anyone have any insite?

  3. #3
    Join Date
    Apr 2007


    WPS Medicare addresses this in a FAQ post but they don't actually answer the question correctly. I have emailed them and they said they would look into correcting it. They haven't yet. This is the link to the site as it currently is.


    Question 6.

    The answer I got in the email (which I received on 10/19/09) is copied and pasted below.

    "Thank you for the inquiry you submitted to Wisconsin Physicians Service (WPS) Medicare regarding the information in one of our Evaluation and Management (E/M) Frequently Asked Questions (FAQs).

    Thank you for bringing this matter to our attention. I forwarded your concerns to the manager of our Medical Review department. He stated that although the information in our answer is not technically incorrect, he understands how it could be easily misinterpreted. He provided the following modified answer to this FAQ for your convenience:

    “By its scope of practice, most Emergency Department encounters would be a ‘new’ problem to the physician. Generally, there is more work associated with a problem that is new to the provider rather than one that is established to the provider. A self-limiting problem is one that usually will resolve on its own or with minimal intervention. However, a problem could be both ‘new’ to the provider and self-limiting. While a ‘new’ problem is an indicator for level of work associated with the encounter, you must still look at the number of diagnoses (difficulty) and management options (complexity) associated with the presenting problem. For example, a hornet sting (patient wandered into a nest) may only require a prescription for palliative care as the diagnosis is apparent (self-limiting) with minimal effects on the patient (other than just being uncomfortable). While a spider bite, (patient may just be assuming it was a spider but is unsure what insect) with significant swelling, pain, and redness moving up the arm from the bite, will be more difficult to determine the diagnosis (poison, allergic, infection) and will probably have a more complex management. While both are ‘new’ to the provider and insect bites, the difficulty of diagnosis and the complexity of the management options are very different. Also, remember that this is only one component of the Medical Decision Making (MDM) component. The complexity of data and risk of morbidity and mortality are also factors in determining the level of MDM.

    “The history and exam components also determine the level of service and are driven by the presenting problem(s). Please remember, the medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a Current Procedural Terminology (CPT) code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. You could have a ‘Moderate’ level of MDM, but have only an ‘Expanded Problem Focused’ history and exam be medically necessary to address the presenting problem. While ‘new’ and ‘self-limiting’ are good indicators of the number of diagnosis and management options, you must still sometimes look at the totality of the circumstances to determine the level of service. The 1995 and 1997 Documentation Guidelines provide guidelines on how the provider can determine the level of work in regards to the number of diagnosis and management options for the presenting problem.”

    WPS Medicare is currently reviewing this FAQ to determine whether we should modify our answer or remove the question from our Website. Please continue to watch our Website at the address you referenced for any changes we may make to this FAQ

    Thank you again for bringing this issue to our attention. If you need additional assistance from WPS Medicare regarding this matter, please include the reference number below in any correspondence. If you need immediate assistance, you may reach our Provider Contact Center at 866-234-7331.


    Kris Strehlow
    Provider Relations Research Specialist
    WPS Medicare

    Ref: 21308 "

    Like I said, they haven't updated the website as yet but they did give me a different answer in the email. Unfortunately this is all I have to go on, hope its helpful. If you want the actual email let me know and I can forward it on to you.

    Laura, CPC, CEMC

Similar Threads

  1. Definition of "to examiner" for MDM
    By torih@nwurology.com in forum E/M
    Replies: 5
    Last Post: 05-13-2015, 03:20 PM
  2. Est prob but pt not seen in >3 yrs
    By prmiller in forum Auditing General Discussion
    Replies: 0
    Last Post: 10-16-2012, 07:07 AM
  3. MDM established problem (to examiner)
    By lverellen in forum E/M
    Replies: 4
    Last Post: 07-27-2011, 12:53 PM
  4. New problem or est. prob
    By Love Coding! in forum E/M
    Replies: 6
    Last Post: 12-31-2008, 09:30 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.