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Question about MDM

  1. Default Question about MDM
    Medical Coding Books
    I have a question we are a urgent care center. If a patient came in 2008 for a back injury which is a new problem worth 3 points. Then the patient came back in in 2010 and hasn't been seen since the 2008 visit for a back injury would you count this as a new problem or an established problem under the number of diagnoses and management options?

    Thank you for you help

  2. #2
    Daytona Beach, FL
    I worked for an Urgent Care and we would consider it a new problem as we we do not take over the care of the patient. Once the patient is seen for the initial issue, they are refered to their primary doctor for further care. If they return to the Urgent Care for treatment two years later, I would consider this a new "onset" of the pain and would consider it a new problem. This is how we handled it - not sure if this is correct. Any other thoughts on this would be helpful.

    Jodi Dibble, CPC

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