You Be the Coder: Differentiating a Self-Limited or Minor Problem in E/M Visit

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 Subscriber

Answer: 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, [...]

- Published on 2012-01-11