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E/M "NEW problem" on auditing forms

  1. Default E/M "NEW problem" on auditing forms
    Medical Coding Books
    I'm pretty sure that this question has been asked and answered before, but I couldn't find it.

    If a consulting provider sees a patient with a problem that he/she has not seen before, but that problem is not new to the primary care provider (hence the request for a consult), is that considered a "new" problem" when choosing code (in MDM) for the consulting?

    I have found both "yes" and "no" answers in my research for the answer. My instructor says "no" but my logic says "yes" and a lot of audit forms that I've seen actually say "new (according to provider)".

    Thanks,
    Coding Student
    Lisa

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default New problem
    A new PROBLEM is new to the provider who is performing the service.

    So if this is the first time THIS doctor has seen the patient for THIS problem it is a new problem.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default New Student
    remember the 3 year rule

  4. #4
    Location
    Dover Seacoast New Hampshire
    Posts
    2,016
    Default
    The patient doesn't have to be a "new" patient in order to have a new problem. An established patient can have a new problem.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  5. #5
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    You may want to check your carriers on this as well. Some third party carriers and Medicare carriers have stated that if the patient has been seen previously by any provider in that practice for the same problem, then it is not a new problem regardless if it is the first time the rendering provider has seen the patient for this problem or not.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  6. #6
    Default New Pt, Different Specialty, Same Practice
    I have been through a pretty extensive round of questions with our Group concerning "New" patient status for a pt that is seen by another specialty within the same group.
    The Guideline per CMS is that if the patient is seen by a different specialty within the same group, the patient is "new". If seen by a specialist for a new problem within the specialty, the pt is "established".
    From my experience, most carriers follow this same Guideline.

  7. #7
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    I understand what the CMS guidelines are for a new vs. an established patient. Some carriers have clearly stated that following the Marshfiled Audit tool, 3 points are not necessaily given to the provider just because the problem is "new" to them on this encounter. Some have stated that if the patient has been seen previously for the same problem by another provider in that practice, then it is not a new problem to that provider.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  8. #8
    Location
    North Carolina
    Posts
    3,126
    Default
    Quote Originally Posted by dballard2004 View Post
    I understand what the CMS guidelines are for a new vs. an established patient. Some carriers have clearly stated that following the Marshfiled Audit tool, 3 points are not necessaily given to the provider just because the problem is "new" to them on this encounter. Some have stated that if the patient has been seen previously for the same problem by another provider in that practice, then it is not a new problem to that provider.
    I agree with Dawson. Not all carriers view a new patient problem, new to the provider (we're NOT talking about the "3 year patient rule"-New v/s Est.)

    (Palmetto)

    Q-Must a problem be new to the patient or new to the provider in order for it to be considered a 'new problem' when scoring diagnosis/management options for an Evaluation and Management Service (E/M)?

    A-In most instances, a new problem is one that is new to the provider and being addressed at that visit. There are two exceptions to this general rule:

    -The initial visit of an established beneficiary in a single specialty group practice setting with a new provider

    -A visit by an 'on call' or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider.

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