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New problem to the examiner

  1. Default New problem to the examiner
    Medical Coding Books
    We are a group of family practice clinics with a shared EMR. A patient came in to one of our clinics to see Dr. A for a UTI. Five days later Dr. B from the same clinic saw the patient in follow-up for the UTI. I’m trying to code for the follow-up visit with Dr. B. Under “Number of diagnoses or treatment options”, would this be considered a new problem to the examiner because Dr. A and Dr. B are different people (and Dr. B has never seen the patient before) or is it an established problem to the examiner because Drs. A and B are both providers from the same group with the same specialty with a shared medical record?

  2. #2
    Smile Kate CPC
    On page 1 of E/M guidelines in your CPT book, "an established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years".

  3. #3
    Location
    Minneapolis
    Posts
    334
    Default
    We audit those as a new problem to the examiner even if their partner of the same specialty saw the patient for the problem.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  4. #4
    Smile
    Quote Originally Posted by bpct6501 View Post
    We audit those as a new problem to the examiner even if their partner of the same specialty saw the patient for the problem.
    I agree with Pam on this one. This is in regards to Medical Decision Making, not the 3 year rule with an established vs. new patient.

    A new problem would be to the "examining physician", no add'l workup - 3 pts.

    A new problem to the "examining physician", additional workup planned - 4 pts.
    Hope this helps....
    Evangelina Frohna, CPC, CEMC

  5. #5
    Default
    I agree with Pam. A new problem is new to the provider, not the patient or the practice.

    Laura, CPC

  6. Default
    It maybe a new problem to Dr. B, but its actually for a follow up visit already being treated by Dr. A who practices at the same clinic. So you would still have to bill with an established patient e/m, wouldn't you because Dr. A already diagnosised her with the UTI?
    Last edited by terridiaz; 11-06-2008 at 02:29 PM.

  7. #7
    Location
    Minneapolis
    Posts
    334
    Default
    Yes, it would be an established patient E/M but for the "Number of Diagnosis and Management Options" portion of the Medical Decision Making, it would be considered a 'new problem'.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  8. #8
    Location
    North Carolina
    Posts
    3,126
    Default
    I, too, agree...

    E/M University Coding Tip:

    Problems are defined relative to the examiner, not the patient. Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. (Do not get this confused with the 3 year rule..New versus Est. patient)

    http://emuniversity.com/MedicalDecision-Making.html

  9. Default
    Hi Acward,

    I work for a dermatology practice with 4 PA's and 4 dermatologists. If a new patient is seen by one of our providers and then see's another for a follow-up, that second provider will be billed as an established patient visit. I never heard of a new patient maintaining new patient status when seeing another for a follow up. Can anyone give me some insight on this? Is this implemented by Medicare guidelines?

    Thanks!

    dscoder74

  10. #10
    Location
    North Carolina
    Posts
    3,126
    Default
    This has nothing to do with the 3yr rule...New v/s Est. We are referring to the medical decision making that is credited to a provider to build the level of his E/M code. As auditors, this is one, very important area for us when we review charts for medical necessity and documentation. The link I provided earlier, gives a decent explanation.

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