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new/established problem

  1. #1
    Default new/established problem
    Medical Coding Books
    Hi friends,

    let me start my doudt with eg - pt. visited for vaginitis 3months back,the next month she visited purely for menorrhagia,now she is back with vaginitis.
    how can i count this problem as established problem or new problem for this visit.
    my physician states that the pt. was cured in the previous visit and this is her new problem.
    any specific guideline for this new or established problem classification.

    all your thoughts are welcome.

    thankyou,
    sunitha

  2. #2
    Wink
    Quote Originally Posted by drsunitha View Post
    Hi friends,

    let me start my doudt with eg - pt. visited for vaginitis 3months back,the next month she visited purely for menorrhagia,now she is back with vaginitis.
    how can i count this problem as established problem or new problem for this visit.
    my physician states that the pt. was cured in the previous visit and this is her new problem.
    any specific guideline for this new or established problem classification.

    all your thoughts are welcome.

    thankyou,
    sunitha
    On this return visit for vaginitis did she see the same provider? New problem means new to the provider not the patient.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Infection treated and cured
    If the previous infection was treated and cured, then it's a new problem.

    I have sinus infections almost every year. One year I had two in the space of 3 months. The first one was treated and resolved. I was A-ok for a couple of months, then a new infection hit and I was back at the doctor's. It was a new problem. (This is NOT the same as chronic sinusitis which can go on for months.)

    BUT ... the doctor's documentation must be clear about this. What about the visit for menorrhagia? Did THAT visit mention "vaginitis - resolved" in the past medical history or ROS?

    Hope that helps.


    F Tessa Bartels, CPC, CEMC

  4. #4
    Default
    Dear,

    it helped me.I catch your point.


    sunitha

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