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New patient with chronic problems HELP!

  1. #1
    Default New patient with chronic problems HELP!
    Medical Coding Books
    Hello everyone,
    If a patient is new to a physician but have multiple chronic problems:htn,dm,chol etc and need refill for current medication, on the patient assessed problems because all this problems are new to this Dr. he should noted all problems as new or listed as unchanged, improved etc.?

    I have this scenario but I believe that since patient is new to Dr. should listed problem as new please correct me if I am wrong thanks!!

    ps. Dr. only refill prescribed med by previous Dr. should still give credit for prescription drug management or not?
    Mildred Nieves, CPC

  2. #2
    The problems count as new under medical decision making. He should comment that they are new problems to the provider (not the patient) as well as give status of the conditions (improving, worse, side effects) and document if he is doing any additional workup on any specific conditon (difference between 3 and 4 points on # of diagnosis).

    You are also correct that it would fall under the moderate category for table of risk taking into consideration prescription medication. He is now managing these meds and falls under his liability.

    Christie Musser, CPC
    Christina Musser, CPC

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