Primary Care Coding Alert

Question: An established patient saw the physician with a new complaint. Through the E/M, the physician discovered the patient had bronchitis and prescribed medication. Should we consider it "self limited/minor" or "new problem/no additional work-up" when coding?Indiana SubscriberAnswer: CPT® defines a "self-limited or minor" problem as one "that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance." In the Table of Risk that is part of the E/M Documentation Guidelines, a self-limited or minor problem is associated with management options such as "Rest, gargles, elastic bandages, [and] superficial dressings."The fact that the physician prescribed medication implies that he considered the problem more than self-limited or minor. Prescription medication is a management option that carries a moderate level of risk in the Table of Risk and is associated with chronic and acute problems, not [...]