Pulmonology Coding Alert

Question: Our pulmonologist saw a new patient and diagnosed her with "colds." In the medical decision making (MDM) section, do we classify it as a new problem or do we consider this as a minor problem?Iowa SubscriberAnswer: Regardless of the fact that this case is for a new patient, a cold (460, Acute nasopharyngitis [common cold]) should be considered in relation to a patient's co-morbid conditions. CPT defines a self-limited or minor problem as "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." This would not be the case in a patient with chronic respiratory conditions such as asthma or COPD. A common cold could complicate these chronic conditions, particularly in the young or old patient populations.Furthermore, CMS guidelines states, "The assessment of risk of the presenting problem(s) is based [...]