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MDM-dx & mgmt options

  1. #1
    Default MDM-dx & mgmt options
    Medical Coding Books
    Question for you...I code ER's and we are having a discussion about the # of dx's for the MDM part of leveling the E&M pro fee. I was always from the school of thought that any problem a patient has that comes to the er, is a "new" problem. There is another person that is playing devil's advicate that is saying that if the patient that comes to the er has a chronic problem that is being treated here today, but was treated in another location the day beofre, that it is an established problem.

    I read in the E&M coding guidelines in the CPT book the following statement...
    "No distinction is made between new & established patients in the emergency room. E/M services in the ER category may be reported for any new or established patient who present for treatment in the ER"

    Now, the first sentence, to me, means that every problem in the ER is looked at as new, but the second sentence is a little confusing to me. I guess I just may not be understanding it correctly.
    Another scenerio presented to me was what if the patient came in for something one day, saw Dr B, and then came in 7 days later for the same problem and ended up seeing Dr B again? can anyone offer any insight on this?

  2. #2
    Milwaukee WI
    Default ER problems New? or established?
    There is a difference between a new patient and a new problem. An established patient can have a new problem. So don't get confused with the CPT guidelines on what constitutes a new or established patient.

    Because ER doctors do not generally provide any continuum of care to patients, it is usually presumed that every problem (not every PATIENT) that comes to the ER is a new problem.

    However, if the ER documentation clearly refers to a patient having been at this ER "yesterday," or "last week" or "3 times this year" for this same complaint, then I'd consider it an existing problem.

    So when I showed up at the ER with a severe nosebleed on Tuesday, and then had to go to the ER again on Sunday with the same problem ... it was an existing problem on Sunday.

    On the other hand ... if I went to my PCP on Tuesday with my nosebleed, but had to go to the ER on Sunday with a nosebleed ... it's a NEW problem to the ER staff because they haven't worked me up or treated me for it recently.

    Injuries, however, are ALWAYS new problems. So if I came in with a bloody nose as a result of an ACCIDENT on Tuesday and came in with another bloody nose as a result of another accident on Sunday, it's a new problem on Sunday.

    (Boy, I sure am having a lot of bloody noses! ... lol)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Thanks Tessa,
    I appreciate your take on this, but is there anywhere else that it may be written so I can take it to my supervisors. What you said definitely makes sense, but the other way makes sense to me too, so I just want to know how an auditor would see it. If you have any additional info, please let me know. You can also PM me if you need to. I sent you one today regarding another issue that I am having. Thanks again for your reply!! Take Care!!

  4. #4
    Milwaukee WI
    Default Carrier specific
    There is at least one carrier that doesn't give credit for a new problem unless it is new to the patient. So once someone is diagnosed with diabetes, for example, that problem would be considered as existing for all future encounters ... even if the patient changed doctors.

    I don't have the exact citation in front of me ... but I know that has explained the Marshfield grid point system as a new problem to the provider.

    Sorry I don't have more than this to give you now.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Thumbs up
    Thanks Teresa and Leslie, this was really useful info for, I believe, all of us.
    Girish Dadhich, CPC

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