# Presenting Problem - the presenting symptom



## Michele1229 (Apr 21, 2016)

Hello -
We are having a debate in my office about the nature of the presenting problem. We are having conflicting views on this and we are currently auditing ER visits. In relation to the table of risk... do you look at the presenting symptom or do you look at what was found after the provider works up the patient. For example... patient presents with chest pain. After workup (labs, xrays, mri's), the provider gives a dx code of chest wall muscle strain  and patient gets meds and goes home. If you go on chest pain that would be high on table of risk because chest pain could be a lot of things - some of which are serious - but if you use the final dx of chest wall muscle strain then this is more a low complexity. Thoughts?
I tend to lean towards using what the provider finds or else wouldn't everything be undiagnosed problem because we are all undiagnosed before we are seen by the doctor. 
Would love input...

Thanks!


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## mitchellde (Apr 21, 2016)

I feel you need to go with the presenting problem as being the complaint of the patient on presentation. Given that the provider has no idea at the time the exact nature of the issue, it requires more complexity to arrive at the answer. You cannot effectively base the providers decision to perform the type of exam and complexity of information based on what he did not know at the time.


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## CodingKing (Apr 21, 2016)

I agree, nature of presenting problem here is what it should be based off. Many things can present as urgent and then turn out not to be. The Provider had to do the medically necessary work to rule it out so that should count. You don't ignore all that work just because in the end it was nothing serious.


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## Michele1229 (Apr 21, 2016)

Thank you both for the reply.
Ok.... so in this situation I gave you guys would use the chest pain to determine what to circle on the table of risk under the presenting problem column?
Which would probably tend to fall under High Complexity since chest pain could be really serious.


I guess one of the arguments being presented in the office was that a great number of people coming to the ER would be 'undiagnosed new problem' in the moderate category because until that provider looks the patient over then everything is technically 'undiagnosed'. So that's why the argument of using chest wall muscle strain was brought up because that is the presenting problem after the provider worked up the presenting symptom. They figured the work involved to determine that would be counted in the 'amount and complexity of data' section of the MDM. 

Do you guys lean a certain way when someone presents with abdominal pain? This is another, like chest pain, that could be very serious or very minor.


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## mitchellde (Apr 21, 2016)

Since for an ER provider this is typically an unknown patient I would go to the serious side.


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## thomas7331 (Apr 21, 2016)

I think we may be confusing complexity with risk here.  If the problem is diagnosed at the visit, you would use that in the risk section of MDM, but that is only one of the components of the MDM.  So in your first example, the chest pain turns out to be muscle strain which is low risk, but the visit is still of moderate complexity MDM because you have a new problem and multiple data points which both put you at the moderate level MDM overall.


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## Michele1229 (Apr 21, 2016)

I would have new problem - no additional workup for the chest pain which is 3 points.
Then provider did xray and labs which would give 2 points for amount and complexity of data.

Then the table of risk is where we were having problems..... no meds were given and no diagnostics ordered so I need to use the presenting problem to determine my table of risk bullet. So if after workup they determine it is muscle strain.... then I agree that falls under low on table of risk and circle the 'acute uncomplicated illness/injury' bullet. 

So that means the overall MDM would be Low complexity overall for the MDM.

BUT.... is there an added part to the equation I need to consider because I know Debra and Coding King said use chest pain... so do I use this to determine overall complexity of the visit????


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## mitchellde (Apr 21, 2016)

For ER we always went with the presenting issues for nature of presenting problem.  If the provider ordered tests and such thinking it was the worst scenario then why should his overall MDM be penalized if it turns out to not be the case.  The patient complaint was still driving the overall encounter, and the provider appropriately took it all under consideration.  Again remember most of the time these patients are not known to the ER provider.


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## thomas7331 (Apr 21, 2016)

I guess I should ask, since you didn't specify in the original post, are you auditing facility ER levels or physician E&M charges?


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## thomas7331 (Apr 21, 2016)

ShelleyP said:


> I would have new problem - no additional workup for the chest pain which is 3 points.
> Then provider did xray and labs which would give 2 points for amount and complexity of data.
> 
> Then the table of risk is where we were having problems..... no meds were given and no diagnostics ordered so I need to use the presenting problem to determine my table of risk bullet. So if after workup they determine it is muscle strain.... then I agree that falls under low on table of risk and circle the 'acute uncomplicated illness/injury' bullet.
> ...



If you're doing an E&M audit, based on what you've said I agree this would be low complexity MDM.  But an ER visit for chest pain must have included an EKG, which is another data point, and generally the ER physicians do an independent review of the images/tracings too which is one more, and if they requested the patient do any additional work-up with a cardiologist as outpatient, that would also bring you to 4 diagnosis point.  So this may indeed have been a moderate to high visit but without complete documentation?  For E&M, you can't use the presenting problem alone to determine the complexity of the visit if the other documentation elements are not there.


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## Michele1229 (Apr 21, 2016)

We are auditing the physician E/M level.

And yes, I forgot the EKG which would be 3 points total. 
No consults or anything done. So that would make it an overall MDM of Moderate.

We just don't want to be doing these wrong because in this case of chest pain that turned into a muscle strain... If we use the chest pain as the presenting problem then on the table of risk that would probably be high. But if we use the muscle strain then that is low on the table of risk. Either way, in this situation, it will score a moderate for the overall MDM but when we fill the audit sheets out we just want to make sure we are circling what is right if the provider wants feedback. 

I was just curious what everyone thought or did who had more ER experience!


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## Michele1229 (Apr 21, 2016)

We are auditing the physician E/M level.

 And yes, I forgot the EKG which would be 3 points total. 
 No consults or anything done. So that would make it an overall MDM of Moderate.

 We just don't want to be doing these wrong because in this case of chest pain that turned into a muscle strain... If we use the chest pain as the presenting problem then on the table of risk that would probably be high. But if we use the muscle strain then that is low on the table of risk. Either way, in this situation, it will score a moderate for the overall MDM but when we fill the audit sheets out we just want to make sure we are circling what is right if the provider wants feedback. 

 I was just curious what everyone thought or did who had more ER experience!


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## mitchellde (Apr 21, 2016)

I guess I just assumed an EKG and CXR would be ordered and read as per routine for a patient that presents with chest pain.


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## thomas7331 (Apr 22, 2016)

Not to beat a dead horse, but one other thought I had is that the E&M documentation guidelines say the _"assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one."_  In that context I think it makes sense to base your risk on the diagnosed problem because that is a better indicator than if you consider the status of the problem at the time of presentation.  in other words, if the physician assesses that the patient's chest pain was due to muscle strain, the risk anticipated after the encounter is lower than if the patient was being discharged with some remaining uncertainty about the diagnosis.


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