Forum - Questions & Answers
Number of Diagnoses or Treatment Option
My co-worker and I are interpreting a section under Number of Diagnoses or Treatment Option differently what are your thoughts? If the doctor orders a Kub on a new patient that comes in with a chief complaint of abdominal pain does that warrant getting credit under new problem (to examiner); additional workup plan? I am leaning toward no. We practice in the state of Florida.
re: Number of Diagnoses or Treatment Option
an xray is a workup. Yes.
re: Number of Diagnoses or Treatment Option
Problems are defined relative to the examiner, not the patient. “New problem, with additional work-up planned” may include any new clinical issue which requires
further investigation such as chest pain, proteinuria, headache, shortness of breath, etc.
re: Number of Diagnoses or Treatment Option
The guidelines themselves don't provide a lot of detail about the MDM section. If the test is completed before the patient leaves the office (urine, quick strep, in office x-ray) I do not count it as additional work up planned.
If the patient is sent for a test/consult and the provider will not have the results at the time of the visit, then I count it as work up planned.
And, I agree: it is new to the examiner, not the patient.