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E/M MDM Table 1: Self limiting/minor vs. New Problem

  1. #1
    Spokane, WA
    Cool E/M MDM Table 1: Self limiting/minor vs. New Problem
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    I have been an auditor for several yrs and have never considered a self limiting or minor problem as a New Problem on the Med Dec Making Table of Risk (Table 1) # of Dx or Management Options. In my opinion and due to the fact that there is a separate box for self limiting (1 pt), it would need to be at least a low complexity problem in order to fall into either the New Problem with (3 pts) or without additional workup (4 pts).

    We have recently been instructed that every self limiting or minor problem needs to be considered as if it were "New Problem with or without additional workup".

    This would easily allow the physician to create a detailed history & provide meds (which the pt expects whether they need it or not) for a self limiting or minor problem and receive a level 4 (assuming Estab pt). This pretty much wipes out any mid-level visits and seems fraudulent to me. I need to find it in writing that self limited or minor issues cannot be considered under the "new problem" boxes in Table of Risk #1 and am having trouble locating anything to back it up.

    Any help would be MUCH APPRECIATED!!!!

  2. #2
    Central Indiana
    Regardless of the treatment offered, all 3 components have to be considered medically necessary. For self-limited or minor problems, I don't see anything over a level 3 being possible. I guess I would need a scenario to wrap my head around a level 4 visit for a minor problem. While I am in agreement with you that a physician charging such a level for minor problems would most likely be considered abuse if not right out fraud, I still see a new problem with no prior history as a new problem. I did not locate any documentation to support your view, sorry!

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