E/M coding questions

pt saw the nurse practitioner for a problem, and a week later sees a physician for same problem.
As it relates to Medical Decision Making....

Is this still a "new problem" to the physician, since it is new to him.

Also what constitutes "additional work up"? A U/A? Blood work? Xrays?

E/M coding questions

Whether or not the problem is new to the partner is not discussed in the Documentation Guidelines. Any one who tells you "yes, it's new" or "no it isn't" is expressing their own opinion. I don't know of any payers or carriers who have addressed that: perhaps someone else does and can chime in.

Additional work is also not defined in any specificity in the guidelines, but I think there is more consensus on that: it is work up that requires a test that will not be available during the visit. If the U/A or quick strep test was performed, and the MD had the results at the time of the visit, most of us do not count it as additional work up planned. If the x-ray or ultrasound or blood work will be performed after the visit, and results will come to the provider after the patient has left the office: yes, additional work up planned.

new problem to the examiner or the patient

Soooooo ~ we are having a debate on this. If a patient is seen at XXX Office by Dr #1 for a new problem of hypertension in April and they return to the same XXX Office in Oct and see Dr #2, and Dr #2 has not seen the patient for this hypertension. Is that a new problem to Dr #2 when giving credit in the MDM or is it an established problem stable or worsening etc?

To the patient

It is an established problem, especially with doctors within the same group

established or new problem ~ can Copapedia editor weigh in as well?

Signature Doc~ thank you for your feedback! WE looked at all the sources we could find on Copapedia, E&M University, and everyday coding by Betsy N and we kept coming across citations that seemed to indicate, (new to the examiner, not the patient, when determining MDM) which seemed to be the opposite as the feedback that copapedia editor was saying in this string ~ thus the confusion ~ So it sounds like this is "opinion" and that "opinion" seems to either conflict or change between the sites mentioned above and potentially the editor (?) Unless we are reading it wrong. If the Editor can respond and also clarify that would be welcomed as well. The coders I have in the Office had it drilled into them from a previous life that it is "new to the examiner, not the patient" and I had not ever heard of that.....so I am challenging them and gathering "opinions" from my esteemed colleaugues! Thanks again!

It is confusing

I think the distinction is going to be hard to find in writing. As I see it, if I am treating a patient for a disease and my partner sees the patient in my absence, it is not a new problem- it is a followup of an existing problem (that could be stable, worsening or uncontrolled). If I see a new patient to my practice who has never seen anyone in my group, with an established disease, it is a new problem. If I refer the patient to a partner that is of a different specialty for a problem that I have been treating, like the hypertensive patient to my cardiologist partner (I am Int med) then it is a new problem to him for his visit.

Think of your practice like a brain

Working for an Insurance (Medicaid/Medicare), the way we looked at it was that one practice represents in a way a single functioning organisim. Each of the Drs that work for the practice are like cells within the brain. Because each Dr has access to all the records of a specific patient, that patients problems that are addressed with one Dr are considered addressed with all Dr.'s within the practice. I don't think I could put it better than signaturedoc, but yes, insurance does consider it to be an established problem. Simularly, if you have a new patient, but they have been to your practice to see another Dr within the last 3 years, you must bill established, not new. This works in much the same way.