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



## cornutts (Aug 13, 2013)

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.


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## MikeEnos (Aug 13, 2013)

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
> ...



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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## cornutts (Aug 13, 2013)

Thank you for your response.


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