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Wiki Is problem a new problem or self-limited problem

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CindyWeems

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Pt. comes in and is diagnoses with Upper Respiratory Infection x 3 days. Would this be counted in an audit as a "new problem" worth 3 points or a self-limited problem worth 1 point? Thanks for helping me out on this.
 
If this is first patient encounter for infection it is a new problem-3 points with no additional work up (or 4 points with additional work up)
 
I think it's very difficult to categorically say what problems are 'self-limited'. (A physician once told me that ALL problems are self-limited because the patient always either recovers or dies!) I think the best practice is to give the provider the benefit of the doubt that it's a 'new problem' unless the documentation makes clear that it is not serious and will resolve without treatment. My experience has been that unless they have a really strong clinical background, if coders/auditors get too deep into deciding that the problems a provider is treating aren't serious, it ends up just causing a lot of friction. But I do recommend taking a look at the clinical examples in Appendix C of the CPT book as it gives you a good starting point for what types of problems might fall into what level of E&M.
 
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