# medical decision making - I am sorry for all the questions



## alices (May 4, 2011)

I am sorry for all the questions, but for the number of diagnoses or tratment option table A is for the pfsh portion or can it be from the hpi example pt has chronic pancreatitis has abd pain on left side and vomiting , psfh has pancreatitis chronic, in my table A I only have  2 since it is an established problem worsening right? thanks for the help..alice


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## btadlock1 (May 4, 2011)

alices said:


> I am sorry for all the questions, but for the number of diagnoses or tratment option table A is for the pfsh portion or can it be from the hpi example pt has chronic pancreatitis has abd pain on left side and vomiting , psfh has pancreatitis chronic, in my table A I only have  2 since it is an established problem worsening right? thanks for the help..alice



Let me see if I understand what you're asking:
You have a patient that has an established history chronic pancreatitis, he came to the ER for vomiting and abdominal pain on his left side, and the doctor mentioned the Hx of pancreatitis in his HPI? There are several factors that you'll need to consider:
1. The pancreas is located in the left *upper* quadrant, so unless this note specifies that he's feeling pain in the upper part  (kind of in the center, really) of his abdomen, you may have to ask the provider to clarify whether or not the abdominal pain/vomiting is related to the pancreatitis. If they are related, you only code the definitive diagnosis, not the signs and symptoms.
2. (Assuming they're not related) Did the provider_ treat _the pancreatitis, or mention any kind of plans regarding it? Or did he just mention it for informational purposes? If he *did* treat/make a plan involving the pancreatitis, then yes, it does count as a problem. If it's not related and not addressed, then its history should only be taken into consideration in the risk portion, as a comorbidity that may complicate treatment for the problem he's fixing.
3. In the ER, since there's no difference between new and established patients, the problem will not be considered 'established' for the ER doctor - 'New problem" or "established problem" refers to how it relates to the *doctor*, *not whether its a brand new problem for the patient.* Whether or not it's 'new' to the doctor contributes to the difficulty of the decision making, because the physician has not formulated his own opinion about the diagnosis, nor been able to try any treatment plans. Obviously, if he had personally dealt with the patient for this issue before, he would be familiar with their health status, and what worked/didn't work in the past.(That's why there's such a big difference in the points for a new problem w/additional workup, and a stable, established problem.)

You don't count something as a problem in the MDM unless it was addressed in the HPI, ROS, or chief complaint. To simplify the E/M requirements to their most basic explanation:
 - The patient has to have a problem, and they have to tell the doctor about it. He asks questions to get a better idea of what the problem might be.
 - He has to examine them to verify their complaint and try to find other signs that might help him figure out what's causing the problem.
 - He then makes a decision on what to do about the problem, and if the patient has other problems that might complicate his plans, then he has to work that into his decision making as a relevant risk factor.

So if the note doesn't indicate that the conditions are related,* and *your doctor mentioned the pancreatitis in his plan 
*or *
if he ordered any diagnostic studies that are clearly related to assessing the pancreas* and *another _relevant_ organ function that could be causing the pain, then you have 2 new problems  - chronic pancreatitis, and abdominal pain
*unless* the doctor indicated that he thinks the vomiting is an indication of a third, _distinct_ problem, it's considered an associated symptom, not a separate problem.[/B] (The same actually goes with the pain, but I wanted to cover all of my bases)
If there are efforts made to diagnose a new abdominal problem, and there's no pancreatitis-related tests/treatment addressed in plan, 
*or* 
if there_ is _one, and the doctor makes it clear that the vomiting is due to the pancreatitis, then you have one problem, presumably with additional workup planned.  Sorry if that was confusing...Hope that helps!


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## btadlock1 (May 4, 2011)

*P.S.*

Pancreatitis is often an indication of gallbladder function problems, so it's reasonable to think that the pain may be due to gall stones, versus pancreatitis, if the patient still has their gallbladder.


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## alices (May 6, 2011)

*re-medical decision*

thank you for your response and yes I think so let me ask you, so if it just says in the hpi that pt has chronic pancreatitis I can use that as a new problem? (pancreatitis was the final dx). See this is where I am getting confused I think, I was told that if it is a chronic problem and it is worsening then it is a 2 so that is what I have been doing and I don't like it because sometimes it just feels and looks like it should be more but because I had that in my head (2 pt for worsening) I automatically gave it 2 pts, I wasn't taking into account that this might be the 1st time my dr had seen the pt i just seen my dr write pt has chronic pancreatitis I put it as the 2.
So if he says pt has chronic condition, or when they say pt has hx of asthma I might still be able to make 3 or 4 depending on the overall chart? I don't just give it the 2 pts? I hope I am not confusing you I sometimes don't explain what I want to say right even though I know what I am trying to say...thank you so much for your help..alice


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## FTessaBartels (May 6, 2011)

*Emergency Room vs Doctor's Office*

The pancreatitis may be chronic, but unless this patient has been treated repeatedly *in the ER* for this, this is an ACUTE problem and is considered a new problem.

E.g. Patient has had diabetes for some years. When he shows up in the ER with blood glucose over 500 ... that is a NEW problem to the ER doctors (who do not normally see him for treatment of his diabetes).  When his internist comes to admit him, it's an established problem, worsening because the internist DOES regularly treat the patient for diabetes. 

And NO - PFSH list does NOT equal # of diagnoses. 

Take that diabetic patient again .... let's say he shows up in the ER with a wrist sprain following a fall. PFSH notes DM2 stable.  If *all *the ER does is x-ray, and prescribe ice, rest, elevate and OTC pain relief then you wouldn't use any dx for diabetes as part of your MDM (NO problem points, NO data points, NO risk factor). 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## alices (May 9, 2011)

*re-medical decision*

Thank you so much for all your help, I am truly gratefull that there is this forum for people like me..thanks again alice


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