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MDM-self limited or new problem in an Urgent Care?

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cornutts

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I work in an Urgent Care so 99% of our patients are presenting with a new problem. I am having trouble deciding what should be considered a self limited problem versus a new problem. A lot of our visits could fall under both catergories. If we are giving a prescription but not doing any labs or xrays, the # of diagnoses or treatment options can determine the level of complexity.
 
This exact scenario can often make the difference in the selection of level of service for a coder or auditor. Unfortunately, you won't find any exhaustive lists to explain what "self-limited or minor" really means. A google search will show you that many people have had this question, and there are few answers. Some people have gotten opinions from their local carriers, but I have yet to see anything to 'hang my hat on.'

CPT defines 5 different levels of Nature of Presenting Problem. Here's the CPT definition of a self-limited or minor presenting problem.
Minimal: A problem that may not require the presence of the physician or
other qualified health care professional, but service is provided under the
physician’s or other qualified health care professional’s supervision.
Self-limited or minor: A problem 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.
Low severity: A problem where the risk of morbidity without treatment is
low; there is little to no risk of mortality without treatment; full recovery
without functional impairment is expected.
Moderate severity: A problem where the risk of morbidity without
treatment is moderate; there is moderate risk of mortality without
treatment; uncertain prognosis OR increased probability of prolonged
functional impairment.
High severity: A problem where the risk of morbidity without treatment is
high to extreme; there is a moderate to high risk of mortality without
treatment OR high probability of severe, prolonged functional impairment
Click to expand...

You will have to use your judgement when determining if a problem is self-limited/minor, or a new problem with no add'l workup. I would hesitate to even say 'Well DiagnosisX is always self-limited/minor.' Even from case to case, I could envision a scenario where it is self-limited/minor, or I can envision a scenario where perhaps it is a bit more severe and I would give credit for a new problem with no add'l workup needed.
 
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