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Posts: 9
Reply with quote  #1 


I have a question about problem points.  If a patient comes in with a new rash, and it's diagnosed as Fifth's Disease.  No further intervention is given except for OTC benadryl prn itching. 


I am stuck on assigning the correct number of problem points

Do you give it:

1)  new problem, no further work up 3 pts


2)  self-limited minor, 1 pt


It's the deciding factor between SF or low MDM.  I can't decide as it's both a new problem and self-limited, which is right to count?




Posts: 39
Reply with quote  #2 
I read a Medicare statement which was a rebuttal of a published article where the author stated you could bill Otitis as level 4.  Her reasoning was that it was a new problem and Rx was given which= level 4.  Medicare emphatically disagreed, and stated that medical necessity wouldn't warrant a detailed history or exam on this patient, and the problem was self-limited with straightforward decision making. 

When I can't decide between new problem or self-limited, minor I go to the table of risk and determine where the problem would fit there.  If it's minimal or low then I count as self-limited, minor; if it is moderate then I count as new problem.  Looking at Medicare's example above, this fits medical necessity which is their overarching criteria. 


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Posts: 773
Reply with quote  #3 
I also got some feedback about the CT Medicare carrier saying the same thing (that otitis media is a self-limited or minor problem).  I think this is going to be one of those gray areas and each doctor needs to get clarification from their own carriers, especially pediatricians who see a lot of these cases.

From a strictly medical point of view, I think sometimes otitis is a self limited problem and sometimes it is not.  There are many pediatricians who DO NOT treat a "routine" otitis with ATBs, but wait and see if the infection will resolve on its own.  In this circumstance, I can definitely see Medicare's point of view.  But if you are prescribing ATBs, I think you can make the argument that this changes the complexity of the encounter by having to consider allergies, potential side effects, etc. 

Also, if you look at the actual e/m guidelines, the only example they give of a self-limited or minor problem is on the table of risk where they use the example of "insect bite or common cold."  So....who knows?


Posts: 9
Reply with quote  #4 
Thanks, I think I've got it now.  So the best way to approach straightforward vs new problem points may be if the patient never came in for treatment the problem would go away on it's own-- so give it 1 problem pt for self-limited (even if it's new).  That would apply in this case of Fifth's disease. 
Just a personal comment, when a patient comes in with a rash there are over 100 things it could be, those need to be considered before narrowing down the diagnosis.  To me, it still feels like a new problem, but can understand the logic that makes the final judgement straightforward.
I tend to agree with Dr Jensen about OM being a new problem 3pts if antibiotics are prescribed.  It's concerning that an auditor has the power to make a judgement like that simply because CMS hasn't written the rules out very well. 
Here's the note and how it was scored at the bottom:
Established Patient:
cc: "rash all over"

HPI: 10 year old male presents with skin rash. Duration: onset 3 days ago, getting worse Location: generalized rash, affecting head, trunk, and all 4 extremities Severity: mild "didn't hardly notice it" Assoc s/s: mild itching, no fevers, no congestion, no sore throat

ROS: no shortness of breath, no n/v/d, other systems reviewed and reported as negative

PMH: denies

Meds: none

allergies: NKDA


VS: 97.9 - 88 HR - resp 16 - 104/60- wt 88 lbs


General appearance: NAD, conversant

Head: normocephalic

Eyes: conjunctiva clear, no ptosis

Ears: normal appearance external ear, EACs patent, and TMs pearly

Nose: external appearance of nose is normal, turbinates and mucus membranes are w/out erythema or congestion

Oral: no erythema of pharynx

Neck: non-tender, no cervical lymphadenopathy

Lungs: clear to auscultation, resps even and unlabored

Heart: RRR, no murmurs, no edema

Skin: macular confluent rash noted on trunk, extremities, and face. Bilateral cheeks are red. Skin is warm, dry, and non-tender to touch.

Psych: mood/affect normal

Assessment: Fifth's Disease

Plan: Mother reassured that virus will run it's course with no further intervention needed. He is no longer contagious and may return to school. May use OTC benadryl or other OTC antihistamine for any itching that may occur. F/up if rash worsens or fails to resolve.

Medical Decision Making:

Problem points:    1 (self-limited)    

Data Points: 0
Level on Risk Table:   low     (OTC med)            

    SF       level of MDM

Final Look:

History level met:    detailed         

Exam level met:     detailed           

MDM level:   SF

Code: 99212  (based on MDM of presenting problem, which is our policy) 




Thanks again for the help. 


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