# Help with medical decision making



## reichtina320 (Feb 13, 2008)

Hi,  Please help!   

Patient presenting with bilateral hip pain that has reocurred.  Provider states dx as osteoarthritis and trochantric bursitis.

Does this count as a minor/limited problem, established problem worse, or 2 self limited or minor problems.

Provider reviews xrays.  1 point for data reviewed.

Patient was advised regarding possible future surgery.  Advised to contact PCP to be managed with analgesics and consideration of anti-inflammatory medication.

Under management options is this zero since he is sending the patient back to the PCP for management?


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## rthames052006 (Feb 13, 2008)

codingangel said:


> Hi,  Please help!
> 
> Patient presenting with bilateral hip pain that has reocurred.  Provider states dx as osteoarthritis and trochantric bursitis.
> 
> ...




A  question before I answer

#1.  Is this the first time this provider has seen this pt


From the way you stated it seems to me like the doc is sending pt back to pcp for management.

If this is the case, it would be  new problem to examiner, no additional work-up would be 3 points.

If this is not the first time this provider has seen the pt, then since it's a recurring problem I'd give it established problem worsening...

Let us know 

Roxanne Thames, CPC


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## reichtina320 (Feb 13, 2008)

The patient is established.....

thanks a bunch for your input.

Tina


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