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 Subscriber

Answer: 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 on the risk related to the disease process anticipated between the present encounter and the next one." A typical common cold carries minimal risk in the average healthy patient, but may be more harmful in patient's with other risk factors or compromised immunity.

Warning: Always encourage your family physicians to include all the other relevant diagnoses (e.g., 250.00, Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) and not just the primary diagnosis. Doing so may potentially change the MDM level and consequently the level of the E/M service.