I would use the self limited problem option is as a secondary diagnosis. A self limited problem is one that would take care of itself if not treated. When I am coding ED I am primarily looking at is it a new problem or a new problem with more work up, such as admit, transfer, or outside followup in order to obtain a diagnosis. The Dx management options are just one part of the MDM - the data section is the second and the table of risk is the third. there must be 2/3 to acquire the proper level.
if a patient is diagnosed with a cold - J06.9 that would be 3 points new problem no other workup)
If the physician did not do any diagnostic tests(labs, xrays... there would be no data points
the risk table - states example of cold under minimal risk - 1 point (If no meds or anything else was done)
This would drop the MDM down to a straight forward decision making
Here's how it changes
A patient comes in with cold symptoms, I do not count each symptom as a dx. I count it as 1 problem. The physician completes diagnostic test bloodwork and xray. That is 2 data points. He concludes that the patient has bronchitis. (3 points no further work up. He sends the patient home with a prescription of steroids, cough medicine and inhaler, that is moderate level risk
If the same patient comes and the physician consults with another healthcare provider because he sees something suspicious on the xray, and refers him to specialist for further testing, (this would change things
The diagnosis management options now are a 4
the data points are a 4 ( 1pt for labs, 1 point for xray, 2 points for consult)
Risk is still moderate
But the MDM now meets a level 4 - high MDM
Now the level of the visit is still dependent on all three areas: History exam and MDM - they all must match up
Hope this makes sense
T~