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New Problem to examiner or patient?

  1. Default New Problem to examiner or patient?
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    Hello Group and Happy Friday!

    I sent a question to a consultant recently and she referred me to the Palmetto Medicare web site and told me that Palmetto does not consider a "new problem" to the examiner as something we can give to the provider. It has to be a "new problem" to the patient only.
    In Iowa our Iowa Medical Society made an audit tool that says New Problem to the examiner.
    This is the first I have ever heard of only giving the provider a new problem if it is new to the patient. It makes sense that if a patient has an established diagnosis and sees a new doctor that the doctor/provider does not have to establish a diagnosis but I just have never audited this way. Especially for ER records. Patients come in with established problems all the time but it is new to the examiner. I suppose if the patient has an established diagnosis but a new complication or progression of the illness that is new to the patient.

    Any thoughts about this?

    Thank You

  2. #2
    Sioux Falls South Dakota
    Every audit tool I've seen and/or used, and every Webinar or workshop I've attended on Auditing says new problem "to examiner", not to the patient. If the problem is new to the examiner, it makes sense that it's a higher degree of medical decision making, to my mind. I deal with both Noridian and WPS for Medicare, and of course multiple insurance companies, who all say new to the examiner.

    I did check the 95 and 97 DG's, and they don't specifically say; but the audit tools from NAMAS, Decision Health, and Trailblazers all say "to examiner" for the new problems.

    I hope this helps!

  3. #3
    North Carolina
    This can become carrier driven. Although Palmetto does recognize that "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.
    Rebecca CPC, CPMA, CEMC

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  4. #4
    Sioux Falls South Dakota
    Medical Billing
    Rebecca, thanks for pointing those out - I always tell our providers that if the patient has seen their "partner", or they are covering for another provider, and it is an established diagnosis for that patient, it is not counted as new in MDM.

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