Wiki Problem is present in multiple locations, i.e., bilateral knee osteoarthritis, both sides were addressed, is it considered 1 or 2 chronic illness(es)?

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thomas7331 said:
I would treat it as one problem unless the provider has written two different treatment plans.
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You really have a good point but I am inclined to consider it as 2 chronic illnesses whether treatment plans for both knees are same or different. This is because maybe after evaluation of both knees, the provider did not find it medically necessary to have different treatment plans, but still did separate evaluation and medical decision making of each joint. Also, not all knee osteoarthritis are bilateral, and if my understanding is correct, bilateral osteoarthritis would require more complex medical decision making compared to those that are unilateral (supposing they have same severity). I would greatly appreciate further inputs on this.
 
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rogelio_hernandez@optum.com said:
You really have a good point but I am inclined to consider it as 2 chronic illnesses whether treatment plans for both knees are same or different. This is because maybe after evaluation of both knees, the provider did not find it medically necessary to have different treatment plans, but still did separate evaluation and medical decision making for each joint. I would greatly appreciate further inputs on this.
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I agree with Thomas. unless there are separate treatments or work up, I would count it as one problem.
 
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rogelio_hernandez@optum.com said:
You really have a good point but I am inclined to consider it as 2 chronic illnesses whether treatment plans for both knees are same or different. This is because maybe after evaluation of both knees, the provider did not find it medically necessary to have different treatment plans, but still did separate evaluation and medical decision making of each joint. Also, not all knee osteoarthritis are bilateral, and if my understanding is correct, bilateral osteoarthritis would require more complex medical decision making compared to those that are unilateral (supposing they have same severity). I would greatly appreciate further inputs on this.
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Exam work is separate from medical decision making. For example, say a dermatologist treats a payment patient for a rash or eczema, it wouldn’t be counted as three or more problems just because it was on multiple different parts of the body. You wouldn’t count asthma as two problems just because the patient had wheezing in both lungs. MDM is generally drawn primarily from the provider’s assessment and plan, not the exam. Every note has to be taken on its own merits, but the fact that the illness manifests in multiple locations and requires additional exam work does not necessarily turn it into multiple problems for MDM. So if there’s a single treatment plan directed at the condition (e.g. ibuprofen to control arthritis pain), I’d consider that one illness, even if it affects multiple locations. But with multiple plans (e.g. referral to surgeon for one knee but the other knee is managed with pain medication or injection), then you’d have an argument to support additional complexity of MDM.
 
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mnuhfer04 said:
Do you think this would be the same for C/S and L/S disc degeneration? That these would be 1 problem if treatment is the same for both?
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You really have to evaluate each note based on what the provider has documented. But in general, I would not count multiple locations of the same problem as separate conditions unless the note shows that the provider has had to make different treatment decisions for each one.
 
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