Look at All Elements of MDM, Not Just Symptoms
Question: An established patient presents with two days of sore throat, congestion, cough, fatigue, and a reported temperature of 100.4°F at home. The clinician documents “acute viral URI,” notes clear lungs, normal oxygen saturation, and a well-appearing patient, and recommends fluids, rest, OTC acetaminophen, and return precautions. The note does not document testing, prescription management, or concern for pneumonia, dehydration, sepsis, or another complication. For E/M leveling based on MDM, may I consider this as an acute illness with systemic symptoms, or is acute uncomplicated illness the better-supported problem category? New Mexico Subscriber Answer: Acute uncomplicated illness is the better-supported medical decision making (MDM) problem category for this situation, as fever and fatigue alone do not establish acute illness with systemic symptoms. The documentation for the encounter should show that the acute illness carries a high risk of morbidity without treatment and that the clinician addressed that higher-risk presentation. In this scenario, the provider documents a routine viral upper respiratory infection (URI) with reassuring exam findings, conservative over the counter (OTC) care, no diagnostic workup, and no prescription drug management. That combination supports low problem complexity instead of moderate problem complexity. Classifying the problem based only on reported systemic symptoms could overstate the MDM and potentially inflate the evaluation and management (E/M) level, leading to upcoding the E/M. Acute illness with systemic symptoms may be supported when the note documents clinically significant systemic involvement or risk, such as persistent high fever with abnormal findings, hypoxia, significant dehydration, immunocompromise, concern for pneumonia or sepsis, diagnostic testing for a potentially complicated condition, or treatment decisions that reflect higher morbidity risk. Coder tip: For E/M MDM, do not equate “fever present” with “acute illness with systemic symptoms.” Code the problem element to the level the documentation supports, and look for the clinician’s assessment of severity, risk, and management — don’t focus on just the symptom list. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
