Internal Medicine Coding Alert

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, gargles, elastic bandages, [and] superficial dressings."

The fact that the physician prescribed medication implies that he considered the problem more than self-limited or minor. Prescription medication is a management option that carries a moderate level of risk in the Table of Risk and is associated with chronic and acute problems, not self-limited or minor ones. Accordingly, many coders follow the thinking that if a problem requires a prescription medication, you've moved away from a self-limiting problem.

Consider this a new problem to code with no additional work-up. Choose the appropriate code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), based on the documentation your physician provides