February 25, 2022 | By J. Paul Spencer, CPC, COC
As an auditor in the post-2021 E/M landscape, one of the more common questions I receive has to do with one of the bullet points found in the “Moderate” line of the new E/M grid labeled “Number and Complexity of Problems Addressed”. While this bullet has been around for as long as I’ve been an E/M auditor, “1 undiagnosed new problem with uncertain prognosis” is still one that causes confusion.
In an attempt to simplify this vexing bullet, allow me to personalize it with a recent example from my 3-dimensional life. You’ll all pardon me for a few moments as I waive my HIPAA rights.
I presented early on a Saturday morning back in early August for my regular 8-week appointment as a whole blood donor. In the course of taking my pulse and vital signs, the gatekeeper deferred me from donating, telling me that I had too many skipped beats in my pulse in a minute to safely donate. I wasn’t particularly happy about being deferred, but knowing that I had a previously scheduled appointment with my primary care physician (PCP), I waited for a more expert opinion.
Four days later, I presented to my PCP and relayed the finding. He checked me with a stethoscope and informed me that the initial finding was accurate. Thanks to my extensive family history of cardiac disease, I am now the proud recipient of premature ventricular contractions (PVCs). He referred me for an echocardiogram, which had a finding of a slightly enlarged ascending aorta, but very little else. The rest of my PCP visit was focused on chronic conditions and the order of the usual battery of laboratory tests. Via secure portal message, my PCP relayed the results and referred me to a cardiologist.
I waited several months for cardiologist availability, distinctly undeterred by my provisional diagnosis. Two weeks ago, the day finally came to see the specialist. He took my history, made reference to the echo results, changed my statin drug to something stronger, and scheduled a CT calcium scan (CPT code 75571; I’m always coding).
I offer myself up as an example of an undiagnosed new problem with uncertain prognosis. Depending on the testing that was ordered, and given the risk of developing full-on arrhythmias or cardiomyopathy, my PVCs are the very definition of an undiagnosed new problem with an uncertain prognosis. It is only through further investigation that my physicians get a better sense of the severity of the problem.
With two visits to compare, we actually have different levels of service based on the third column of our medical decision-making grid. My PCP sent me for an echocardiogram. Under the 95/97 table of risk, an echocardiogram was listed as straightforward risk, but coupled with the order of the lab tests, the visit rises to low complexity, and therefore a 99213.
The cardiologist has a similar presenting problem, but since there was prescription drug management, he has the ability to report 99214.
Bear in mind that as a patient, I only have my after-visit summaries until such time, like any other patient, I request my own records for review, so my estimates of the levels of service are based on observation only, but I bet I’m fairly close.
While an undiagnosed new problem with uncertain prognosis may not lead to further testing in every case, the ordering of a test unusual to the patient (in my case, an echo and a CT, respectively) can often be an indicator of a problem matching this description and complexity.
Feel free to take this example forward into your auditing lives, and as a pleasant coda, my CT calcium score ended up being 0% and I’ve been discharged from further care by my cardiologist. I now end this audit tip and return to my regularly scheduled McMuffin.