You have a patient that has an established history chronic pancreatitis, he came to the ER for vomiting and abdominal pain on his left side, and the doctor mentioned the Hx of pancreatitis in his HPI? There are several factors that you'll need to consider:
1. The pancreas is located in the left upper quadrant, so unless this note specifies that he's feeling pain in the upper part (kind of in the center, really) of his abdomen, you may have to ask the provider to clarify whether or not the abdominal pain/vomiting is related to the pancreatitis. If they are related, you only code the definitive diagnosis, not the signs and symptoms.
2. (Assuming they're not related) Did the provider treat the pancreatitis, or mention any kind of plans regarding it? Or did he just mention it for informational purposes? If he did treat/make a plan involving the pancreatitis, then yes, it does count as a problem. If it's not related and not addressed, then its history should only be taken into consideration in the risk portion, as a comorbidity that may complicate treatment for the problem he's fixing.
3. In the ER, since there's no difference between new and established patients, the problem will not be considered 'established' for the ER doctor - 'New problem" or "established problem" refers to how it relates to the doctor, not whether its a brand new problem for the patient. Whether or not it's 'new' to the doctor contributes to the difficulty of the decision making, because the physician has not formulated his own opinion about the diagnosis, nor been able to try any treatment plans. Obviously, if he had personally dealt with the patient for this issue before, he would be familiar with their health status, and what worked/didn't work in the past.(That's why there's such a big difference in the points for a new problem w/additional workup, and a stable, established problem.)
You don't count something as a problem in the MDM unless it was addressed in the HPI, ROS, or chief complaint. To simplify the E/M requirements to their most basic explanation:
- The patient has to have a problem, and they have to tell the doctor about it. He asks questions to get a better idea of what the problem might be.
- He has to examine them to verify their complaint and try to find other signs that might help him figure out what's causing the problem.
- He then makes a decision on what to do about the problem, and if the patient has other problems that might complicate his plans, then he has to work that into his decision making as a relevant risk factor.
So if the note doesn't indicate that the conditions are related, and your doctor mentioned the pancreatitis in his plan
if he ordered any diagnostic studies that are clearly related to assessing the pancreas and another relevant organ function that could be causing the pain, then you have 2 new problems - chronic pancreatitis, and abdominal pain
unless the doctor indicated that he thinks the vomiting is an indication of a third, distinct problem, it's considered an associated symptom, not a separate problem.[/B] (The same actually goes with the pain, but I wanted to cover all of my bases)
If there are efforts made to diagnose a new abdominal problem, and there's no pancreatitis-related tests/treatment addressed in plan,
if there is one, and the doctor makes it clear that the vomiting is due to the pancreatitis, then you have one problem, presumably with additional workup planned. Sorry if that was confusing...Hope that helps!
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