Revenue Cycle Insider

Shoring up your coding with documentation can prevent payer downcoding in acute illness encounters.

As payer audits grow more aggressive and downcoding becomes increasingly statutory, it’s more important than ever for providers and coders in pediatrics, primary care, family medicine, and internal medicine to understand — and clearly document — the distinction between acute uncomplicated illness and acute illness with systemic symptoms.

This difference can directly impact evaluation and management (E/M) level selection, claim reimbursement, and appeal success — especially for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) services.

See What’s Happening in 2025

In 2025, payers are increasingly denying 99214 and 99215 (… 40 minutes must be met or exceeded.) claims based solely on diagnosis codes, disregarding the broader clinical picture and the provider’s actual medical decision making (MDM). This automated approach often results in preemptive downcoding to 99213 (… 20 minutes must be met or exceeded.), even when documentation clearly supports moderate complexity.

And the trend is no longer subtle. As BCBS of Massachusetts recently stated in an email to providers: “We will expand our prepayment claims editing to review professional services for evaluation and management (E/M) overcoding. We will assess level 4 and 5 E/M codes to determine if the level of service billed is appropriate for the severity of the member's condition as reported on the claim. If we identify overcoding, we may adjust reimbursement to a lower-level E/M.”

In other words, diagnosis alone no longer tells the story — and may even trigger automatic review. The only reliable defense? Specific, risk-based documentation that aligns with current CPT^® E/M guidelines and clearly articulates why a higher level of service was warranted.

The CPT^® Framework: Acute Illness Categories

Knowing how to categorize acute illness is crucial. According to 2021 CPT^® guidelines, acute, uncomplicated illness or injury is a short-term condition with low risk of morbidity and a full recovery expected. Examples include uncomplicated upper respiratory infection (URI), sore throat, sinusitis, conjunctivitis, simple urinary tract infection (UTI), and acute bronchitis (mild).

Acute illness with systemic symptoms involves a significant risk of morbidity if untreated, often affecting multiple organ systems or leading to physiological compromise, including pneumonia, pyelonephritis, colitis, influenza with dehydration, and cellulitis with fever.

Importantly, generalized symptoms (like mild fatigue or low-grade fever) in otherwise minor illnesses do not qualify as “systemic” under this definition.

Try This Acute Bronchitis Case Study for Coding Clarity

Acute bronchitis is a common diagnosis across all age groups — and a frequent source of coding confusion.

Example: An otherwise healthy patient with mild symptoms, no fever, and no respiratory compromise is typically a 99213-level visit due to low complexity. But consider a patient who presents with:

• High fever (≥ 102°F),
• Persistent cough with wheezing or mild respiratory distress,
• Marked fatigue or malaise, or
• Comorbidities such as asthma, COPD, diabetes, or heart failure.

In this context, the condition qualifies as acute illness with systemic symptoms — a moderate-complexity problem — and a 99214 may be fully supported.

The diagnosis didn’t change — the risk did. And that risk must be reflected clearly in the documentation.

Debunk the ‘Rx = 99214’ Myth

Prescribing medication, including antibiotics or inhalers, does not, on its own, support moderate complexity. Under CPT^® definitions:

1. Systemic symptoms must reflect current morbidity risk, not hypothetical complications.
2. Diagnosis-based downcoding is valid only if documentation fails to support increased complexity.
3. Code 99214 is supported when:

• Risk is moderate (e.g., prescription drug management), and
• Either the Data or Problem category is also moderate.

That means 99214 can still be appropriate — but only if your documentation tells the full story.

Know Why Documentation Is Your Best Defense

Since the 2021 E/M guideline revisions, history and physical exam no longer determine the level of service — only MDM or time does. As a result, auditors may not thoroughly review the entire note. Instead, they often focus directly on the assessment and plan, where clinical reasoning, risk, and complexity should be clearly documented.

If systemic symptoms, comorbidities, or complications are not explicitly addressed in that section — even if they were evaluated — the visit may be downcoded, regardless of the clinical work that was actually performed.

When you’re documenting the encounter, be clear: “Patient febrile to 103°F, wheezing noted on auscultation, moderate respiratory effort observed. Albuterol administered in-office. Prescribed steroids and follow-up within 24-48 hours” or “Patient with poorly controlled diabetes presenting with UTI symptoms, fever, and mild dehydration. Labs ordered to assess for pyelonephritis.”

The goal is to support the complexity with facts, not assumptions.

Try These 4 Action Steps

Coders can help providers bolster their documentation with these four ideas:

1. Train providers on MDM language — especially how systemic symptoms and risk drive E/M level.
2. Use templates or phrases to prompt documentation of relevant symptoms, complications, or comorbidities.
3. Audit high-volume diagnoses that commonly fall between 99213 and 99214.
4. Appeal when appropriate: If documentation supports moderate complexity, fight the downcode with CPT^® definitions and clinical rationale.

Tell the Full Story With Diagnosis Codes

In addition to clear documentation, accurate and comprehensive diagnosis coding is essential to support the level of service reported. The claim must reflect not just the primary diagnosis, but also any relevant comorbidities, complicating factors, or key signs and symptoms that help establish the visit’s complexity.

When these elements are captured through ICD-10-CM codes, they help paint a more complete picture of the patient’s condition — and can strengthen the claim’s defensibility if the E/M level is challenged. If complexity is clearly documented in the note but not represented in the diagnoses submitted, auditors may overlook the justification entirely.

In short: Your documentation tells the story, but your diagnosis coding helps prove it.

Final Word: Prioritize Clarity Over Assumptions

Not every sore throat, cough, or UTI is low complexity — but not every one is moderate, either.

In 2025, coders shouldn’t have to guess, and payers won’t assume.

Your documentation is what justifies the code: It’s what defends the care you provided.
And in this environment, it’s the difference between getting paid and getting denied.

Clear documentation not only protects your coding — it validates your provider’s MDM, supports appropriate reimbursement, and ensures success if an appeal is necessary.

Donna Walaszek, CCS-P, Northampton Area Pediatrics, Northampton Massachusetts