Wiki Acute Illness with Systemic Symptoms

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Tamilraj

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Good Morning,

Any one please give a good clarity, When we will select the "Acute Illness with Systemic Symptoms" point under Number and Complexity of Problems Addressed in MDM table.
recently I got an error from client end in that chart they have documented final impressions "CLINICAL IMPRESSION Acute fever Acute febrile illness Acute viral pharyngitis. Acute viral (suspected) pharyngitis. Influenza type A with pharyngitis. Possible cough", in this scenario they revised the point from uncomplicated illness to Acute Illness with Systemic Symptoms. Kinly help me to get clarity on this point selection.
 
Tamilraj said:
Good Morning,

Any one please give a good clarity, When we will select the "Acute Illness with Systemic Symptoms" point under Number and Complexity of Problems Addressed in MDM table.
recently I got an error from client end in that chart they have documented final impressions "CLINICAL IMPRESSION Acute fever Acute febrile illness Acute viral pharyngitis. Acute viral (suspected) pharyngitis. Influenza type A with pharyngitis. Possible cough", in this scenario they revised the point from uncomplicated illness to Acute Illness with Systemic Symptoms. Kinly help me to get clarity on this point selection.
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The conditions you describe would not be considered 'systemic symptoms'. The patient has symptoms consistent with some form of acute respiratory infection, seemingly viral and limited to the respiratory system. For a condition to be systemic many systems would need to be affected (that's what systemic means) leading to a higher risk of morbidity.

Since you haven't included information as to the treatment, tests performed, or the severity of the patient's symptoms, the overall level of MDM cannot be ascertained but with regards to number and complexity of problems addressed I would consider this to be low rather than moderate. Others may disagree.
 
It always comes back to the definitions.

Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

Agree as above, without the full documentation we can't really give 100% answer. However, I would agree what you described above is not acute with systemic. Unless there are other things going on or co-morbid conditions or other problems not listed here.
 
Will this call under Acute illness with systemic Symptom? Acute Cough, - Rx given, Acute Laryngitis - RX given, Influenza A and B by PCR negative, post-nasal drainage. Pertinent negatives include chills and fever.
 
This is similar to the original question on this thread - there are no systemic (meaning many systems affected leading to increased risk of morbidity) symptoms documented. The only system affected is the respiratory system. Cough, laryngitis, PND. You don't say what Rx was given (I'm assuming antibiotics).
Impossible to assess the level of MDM without further documentation but low number and complexity of problems addressed.
 
This is a tricky situation and I believe the provider's documentation will likely lead us to the correct answer. I recently found this coding toolkit on the AMA website. Please look at page 11: www.ama-assn.org/system/files/steps-forward-documentation-coding-toolkit.pdf
If you look at the 5th coding scenario, it is a 3 y/o who is diagnosed with Right Acute Otitis Media, febrile. No other major "systemic" symptoms (other than fever) and they chose "acute illness or injury with systemic symptoms" for the problems addressed. The patient was prescribed Amoxil and a level 99214 was chosen for the LOS. Let me know what you think.
 
blaymon said:
This is a tricky situation and I believe the provider's documentation will likely lead us to the correct answer. I recently found this coding toolkit on the AMA website. Please look at page 11: www.ama-assn.org/system/files/steps-forward-documentation-coding-toolkit.pdf
If you look at the 5th coding scenario, it is a 3 y/o who is diagnosed with Right Acute Otitis Media, febrile. No other major "systemic" symptoms (other than fever) and they chose "acute illness or injury with systemic symptoms" for the problems addressed. The patient was prescribed Amoxil and a level 99214 was chosen for the LOS. Let me know what you think.
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Interesting. That directly conflicts with the definition and direction: "For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury." Also, interesting that on that example they don't even have this option listed: Acute, uncomplicated illness or injury. Is an ear infection with a fever where they give them amoxicillin and ibuprofen and there's nothing else wrong where they tell them to come back in two weeks really a 99214? I would say no according to the note they have there.

I agree, it will always come down to the individual documentation and patient scenario.
 
amyjph said:
Interesting. That directly conflicts with the definition and direction: "For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury." Also, interesting that on that example they don't even have this option listed: Acute, uncomplicated illness or injury. Is an ear infection with a fever where they give them amoxicillin and ibuprofen and there's nothing else wrong where they tell them to come back in two weeks really a 99214? I would say no according to the note they have there.

I agree, it will always come down to the individual documentation and patient scenario.
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I have been a PA for over 20 years and a CPC, CEMC for over 8 years. When I read the definition above, the important wording to me is "...may be treated to alleviate symptoms", I am thinking they are referring to a viral illness with fever, body aches, etc.. Perhaps the provider can treat the patients symptoms (cough or sinus congestion) in a URI with a prescription medicine. The first line in the definition of "acute, uncomplicated illness or injury" is "A recent or new short-term problem with low risk of morbidity for which treatment is considered". If a patient has an otitis media, I am not considering treatment, I will treat it. Provider documentation will be the key factor. Another thing I consider when choosing acute illness with systemic symptoms is the Systemic Inflammatory Response Syndrome (SIRS). In an adult, there are four criteria: temp >100.4, HR >90, RR >20, or leukocytosis/leukopenia. If two of these criteria are met, your patient has SIRS. As the name implies, this is a "systemic" illness. Good discussion for all coders and providers!
 
blaymon - Good answer with reference to provider documentation will be the key factor; also SIRS is a great example of acute illness with systemic symptoms.

As a general rule it would be incorrect to label a child with an acute URI/otitis media with additional symptoms of fever with the same severity as an adult with symptoms of SIRS. Fever does not automatically = systemic.
 
Remember that the documentation must, also support medical necessity.

In general, I would not consider acute otitis media a Moderate level of service, but as has been mentioned, it all depends on the documentation.
 
Pt is coming with cough, nasal congestion & headache, Assessment plan : Acute Recurrent maxillary sinusitis with Rx given Amoxicillin, can we consider in MDM problem point as Acute illness with systemic symptoms & Risk is moderate, please suggest E&M level ?
 
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