Wiki Diagnosis/Management Options clarification on MDM

[naenae4]

Can anyone please clarify? We have a large family practice, multi specialty clinic. There is some confusion among our coders on what is considered an existing condition or new condition for a provider. Some believe we should be coding (a New Problem - additional work/no additional work) according to if it is a new condition for the whole clinic vs a new condition to the specific provider now seeing the pt for this DOS. It can definitely make a difference for some of our visits.

So far everything I can find refers to this statement "New Problem – A new problem is defined as one that is being addressed by the practitioner (not patient) for the first time. They are outlined by whether or not additional work up is planned"

Please help settle this discussion and get us all on the same page.

 

[lhamilto@ufl.edu]

New Problem - to whom?

Does your practice have providers with multiple billing specialties? I would consider a problem to be new if it is new to providers in your practice with the same billing specialty. If the patient has seen a general cardiologist in your practice for heart failure and then comes back 6 months later and sees another general cardiologist for heart failure, that would be an established problem for the general cardiologists in your practice. It wouldn't be ethical, or good patient care, to transfer a patient from one general cardiologist to another within your practice in order to be able to bill the patient's problems as new. If your general cardiologist consults another specialty within your practice, then the problem would be new again.

 

[thomas7331]

I'd agree with the last post completely. In CMS regulation and many private payer policies there is language to the effect that different providers of the same specialty within the same practice are to be considered to be 'the same provider' for coding and payment purposes. Providers of the same specialty who cover each other's patients should not be up-coding simply because they are not the original provider in the practice who evaluated that patient - this would be an inappropriate practice both for coding as well as just in terms of good customer service to the patient. If the patient is seeing a provider of new specialty never seen before in the practice, that provider can consider a problem new since they are evaluating the patient for the first time within the context of their particular specialty which warrants the higher level of MDM.