What does a new vs. established problem mean in medical decision making (MDM)?
A former billing auditor told me that in MDM, “new problem” means new to the provider and “established problem” means established to the provider.
This means if you see a patient with a history of DM on Metformin who changed doctors and comes to see you for the first time, if you manage his DM and also refill med, that is level IV as far as the MDM section is concerned. And it can be billed as level IV if the history and physical sections are appropriate.
The National Government Services, Inc, is a company that is a CMS Contracted Agent. Their Evaluation & Management Documentation Training Tool also says the same thing.
See the link below for their full training tool.
Novitas Solutions on their website:
“Do the terms “new” problem and “established” problem on the 1995 E&M Score Sheet under the number of diagnoses or treatment options section of the medical decision-making component mean the same as the Current Procedural Terminology (CPT) Manual’s definition of “new” vs. “established” patient?
The terms “new” vs. “established” problem on the 1995 E&M Score Sheet 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. 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.
The CPT definitions refer to whether or not the patient is new or established to the examiner.” See CMS’s definition of a new vs. established patient.
The American Academy of Child and Adolescent Psychiatry also says the same thing in their coding guide found on the acbhcs.org link below.
Established problem (to examining physician); New problem (to examining physician);
References
E and M Training Tool from National Government Services, Inc, A CMS Contracted Agent.
https://engage.ahima.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=ab03a790-0934-4e9c-a985-9d692b4feeef Last Accessed June 2019.
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00004952 Last Accessed June 2019.
http://www.acbhcs.org/providers/QA/docs/training/E_M_Doc_Training_Resources.pdf