Primary Care Coding Alert

You've hunted for new problem specifics; we've found the details for you.

Your FP gets more medical decision making points for a new problem, but when his partner has already seen the patient for the problem, determining if the problem is still 'new' proves elusive. Here's the skinny on the rules you've got to follow before giving new problem credit.

Capture More MDM Points Depending on Problem's Status

Under Medical Decision Making Number of Diagnoses or Treatment Options, the standard audit worksheet gives 1 point for a stable or improved established problem and 2 points for an established problem that is worsening. But for a new problem, the physician gets a whooping 4 points when additional workup is planned and 3 points when no workup is planned. The problem has to be new to the examiner, according to the Highmark Medicare Services Documentation Worksheet (www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf).

Catch: "Is the problem considered new when a physician in a group practice sees an established patient and this is the first time the physician is treating the patient?" asks Jane Anderson, CPC, with Ohio's University of Cincinnati (UC).

Check Your Policies Interpretation of New

The answer depends on your contractor. For WPS (Wisconsin Physician Services, the Medicare Part B contractor for Wisconsin, Illinois, Michigan, and Minnesota), "'new' applies to the whole group," said Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC, COBGC, in "Hospital Coding ... Making the Rounds" at the 2010 American Academy of Professional Coders Annual Conference in Jacksonville, Fla.

Example: FP Sports saw Mr. Tennis for knee pain in January. In July, Dr. Sports partner, FP Pain sees Mr. Tennis again for the same problem. "Since the physicians are in the same group with the same specialty, this would be an established problem," according to the WPS FAQ, "Evaluation and Management (E/M) Questions and Answers (Q&As) - Medical Decision Making (MDM)" . The policy explains its reasoning with "CMS considers physicians within the same group with the same specialty as the same person. Neither the 1995 nor the 1997 Documentation Guidelines (DGs) indicate any distinction in the examiner."

Highmark, however, sticks with the definition that the problem must be new to the examiner as indicated on its audit worksheet. "The terms "new" vs. "established" problem on the 1995 E/M Scoresheet under the number of diagnoses or treatment options section of the medical decision making component do not mean the same as the definitions of "new" vs. "established" patient in the CPT manual," according to "New vs. Established Problem" (https://www.highmarkmedicareservices.com/partb/em/new-vs-established-problem.html). "The terms on the E/M Scoresheet refer to whether or not the problem is new or established to the examiner, e.g. physician/NPP and whether or not that problem is stable/worsening or whether the physician plans to conduct additional workup on that problem or not."

Bottom line: Check your contractor's and major insurers' policies. For Highmark (MAC Part B for Delaware, the District of Columbia Metropolitan Area, Maryland, New Jersey, and Pennsylvania), you can consider a new problem one that is new to the examiner.