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Initial Hospital Care - Always a new problem?

  1. Default Initial Hospital Care - Always a new problem?
    Medical Coding Books
    Scenario - 16 year old has chronic headaches and is followed by Neurology for the issue. Patient's headache worsens and the patient is admitted by Neurology for IV treatment. Admitting provider doesn't appear to have seen the patient in the Neurology clinic. Under the "Number of Diagnosis" in the MDM, would this be a new problem or an established problem? Furthermore, are all inpatient visits considered independent of any prior visits to a division even if the patient is being followed in the outpatient setting for that condition? Specifically are all inpatient conditions considered new problems?

    I hope this isn't too confusing to follow! Any input would be greatly appreciated. Thank you!

  2. #2
    Milwaukee WI
    Default New problem to physician
    You wrote: "Admitting provider doesn't appear to have seen the patient in the Neurology clinic."

    If the admitting provider has not previously seen the patient, then it is a new problem, even if the patient has been seen by someone else for the same problem numerous times.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default Established outpatient / new problem inpatient chemo?
    Patient is seen in our office regularly. Patient receives chemo at the hospital and we are the admitting service. For the MDM: Levle of Risk = high for the chemo. For the dx and treatment options are we stuck at 1 or 2 points or because its a "new" admit can we get 3 or 4 points? Thanks

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