Self Limited or Minor Problem

lhohler

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I struggle with determining if a problem is self limited/minor or a new problem w/ w/o add'l workup. Can anyone give me examples or what they consider to be a self limited or minor problem.
 

mcpalmeter

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If you can determine from the documentation that the problem is new to the examiner, then credit for the new problem. Now as far as additional work up is concerned, I guess it depends on the location of service. If office, then any referrals to specialists or diagnostic tests ordered for subsequent encounters would be included in additional workup. It is a little different in the Emergency Department. Some folks only credit admissions and consultations from the ED as additional work up while others credit any additional tests needed to whittle down the differential diagnoses as additional workup.

I hope this helps.

Best Regards,

-Maryann C. Palmeter, CPC
 

mmelcam

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If your physician has never seen the patient before for this problem then it is a new problem. Even if the patient has had this problem for years, it is still a new problem for your physician.
 

Kris Cuddy

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Sometimes it is a struggle to determine whether it should be the 'new' or the 'self-limited/minor'.

After auditing documentation for eight years now, I just recently had a revelation on this; The provider may see the problem/condition as self-limited or minor and, if so, we auditor's truly do need to se it that way also.

Check with the provider. Ask him/her to tell you whether they consider it to be self-limited or minor and ask them to guide you in understanding why the view it that way.

Once I did that with one of my providers, my clarity and understanding on what to choose improved dramatically and my providers are no longer under-coding levels of E/M anymore.

Hope this helps,

Kris
 

khaspert

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self-limited/minor

This can be a very gray area. I feel for you. This is my take on it. If the physician or NPP has never seen the patient for what ever the presenting problem is, it is a new problem. The only time I would call it a self-limited or minor problem would be if the problem would have resolved itself without coming in to see anyone. For example, an uncomplicated bee sting, a cold or a hangnail. However, I rarely use this category because this is not usually how it happens.

Additional work up means to me, anything the physician or NPP is ordering to further evaluate the patient in order to make or confirm a diagnosis. I have been told by other coders that if a patient is referred to another physician for further work up this would not count as additional workup since your physician or NPP will not be doing the work.

Well there it is for what it is worth. Good luck.

Kim
 

azwilson2

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self limited or minor problem

The examples that are given are colds, insect bites, tinea corporis, etc. The medical dictionary defines it as " limited by one's or its own nature; specifically : running a definite and limited course <the disease is self–limited, and the prognosis is good"

Hope this helps!
 

btadlock1

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Look at the clinical examples in Appendix C of your CPT...you can find self-limited under 99201, and low under 99202. The examples provided here are good though. Self-limited = will go away by itself. Low = there's a remote chance that it might get worse without treatment eventually, but it will probably be okay without significant treatment (eg, sinusitis, ear infection, benign lesion, dermatitis, etc.)
 

ljstoker

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self limited/minor vs established

I have a question along the same line. I am in dermatology and if a patient comes in for new mole and we dx it as a Melanocytic Nevi (benign). Is this still a minor dx because it would not be treated or a new because we never dx them with this before? My established problems I would say are my acne, dermatitis and eczema being that they require treatment?
 

CatchTheWind

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I am also in dermatology, and there really does not seem to be a clear definition of what is self-limited or minor. In general, I would call it a new problem if it requires treatment (or biopsy, or "watching"), but a self-limited or minor problem if the plan is just "reassurance" or "use sunscreen."
 
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