Wiki Acute or acute with systemic symptoms

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mskitaly09

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I been going back and forth with the acute vs the acute with systemic symptoms. For this example below I went with the acute with systemic based on fever, strep, decreased appetite, and sore throat. The provider also prescribed a prescription which this would be a 99214. Any feedback would be helpful! Thank You!
Reason for Appointment
1. Patient is accompanied by mother and grandmother c/o fever and decreased appetite for the past 2 days.
History of Present Illness
Analysis of Problem:
Discussed Chief Complaint with parent- agree with details documented by nurse.
15 mnth male with fever- Temp max 102
Fever started yesterday
no v/d
no travel recently
drinking liquids
less than usual voiding but voiding
no rash
no daycare
slept ok
no uri symptoms.

Vital Signs
Temp: 99.0, HR: 132, Ht: 33.0 in, Wt: 28lbs 1.5oz, BMI: 18.14 Index, Pulse OX: 100.
Examination
General Examination:
Observation well developed and well- nourished, NAD, alert.
HEENT Head NCAT, Eyes PERRL, conjunctiva clear, TM's LT WAX NOT ABLE TO REMOVE, RT CLEAR , , Nose patent without discharge, Oropharynx hyperemia, Tonsils erythematous without exudate, MMM.
Neck, Thyroid : supple, non-tender, no thyromegaly, AC LN slighty enlarged bilaterally.
Heart: RRR, no murmurs.
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales, good air entry bilaterally.
Abdomen: soft, non-tender, non-distended, , no guarding or rebound, no masses palpated, no hepatosplenomegaly.
Extremities: No clubbing, cyanosis or edema.
Skin no rash or skin lesions.
Assessments
1.Strep pharyngitis - J02.0 (Primary)
2.Sore throat - J02.9
3.Exposure to COVID-19 virus - Z20.822
Treatment
1.Strep pharyngitis


Start Amoxicillin Suspension Reconstituted, 400 MG/5ML, 7 ML, Orally, twice a day, 10 days, 140 ML, Refills 0
Notes: Symptomatic care. Encourage fluids. Complete prescribed course of antibiotics. Tylenol or Ibuprofen prn pain. Call if fever persists longer than 48 hours after starting antibiotics, if less than 4 voids in 24 hours, if sore throat does not improve in 48 hours or if any other concerns. Please bring child in for Well Child Check Ups (Physicals) once a year.
2.Sore throat
LAB: Rapid Strep (Collection Date & Time - 07/21/2025)
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​
​
Value​
Reference Range​
Strep A​
Positive​
​
​
LAB: Flu + SARS Antigen FIA (Collection Date & Time - 07/21/2025) Negative Sars, Negative Flu A & B
Notes:
Return for sore throat that lasts longer than 5 days, poor fluid intake, vomiting, less than 3 urine outputs in 24 hours, lethargy, rash, difficulty breathing/swallowing, or any other concerns. Encourage fluids. Tylenol or Ibuprofen as needed for pain. Please schedule yearly check ups.
 
We run into this issue in our pediatric office a lot - what I've been doing with some success (depending on the payer of course, Anthem loves downcoding our 99214's.
If there is a cough, rash, or any sinus/ear symptoms with strep, I code it as systemic symptoms, since the sore throat symptom has spread to other areas of the body.
With a historian and 1-2 tests ordered, these visits usually end up as 99214s. However, Anthem very rarely pays it as a 99214, and will often downcode to 99213. This is ongoing with them, and Aetna has begun downcoding occasionally too.
 
It's a debated topic. Depends on the documentation of the specific encounter. It's probably a 3.

The snips below are from ACEP and they are talking the ED setting, but may help with understanding. https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs
  • Acute, uncomplicated illness or injury: A recent or new short-term problem with a 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.
  • Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment.
    • Systemic symptoms may not be general but may affect a single system.
    • For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury.
  • Fever is generally considered to likely represent a systemic response to an illness. CPT states that fever associated with a minor illness that may be treated to alleviate symptoms is more typical of an uncomplicated illness. For example, an otherwise healthy patient with a fever solely associated with uncomplicated viral URI symptoms is a less concerning clinical process. However, fever or body aches not associated with a minor illness or associated with illnesses that require ordering a test or prescription drug management may represent a broader complexity of problem being addressed or treated.
This link talks about it:


https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/emcoding-series-part-three.html (see snip below)

Acute illnesses​

Identifying the problem level of chronic illnesses is relatively simple because there are often objective measures (e.g., A1C for patients with diabetes) to determine whether they are stable or unstable. It is slightly more subjective for acute illnesses, but the key factor is whether the illness, left untreated, would likely result in hospitalization or death.

When determining the level of service for office visits involving acute illnesses, here’s what to remember:
  • Uncomplicated acute illnesses, such as urinary tract infections (UTI), sinusitis, or sore throat are usually level 3 problems. If you do not treat them, they will not usually result in hospitalization or death.
  • Acute illnesses with systemic symptoms, such as pneumonia, colitis, or pyelonephritis are usually level 4 problems. These are conditions where there is a possibility of significant harm, including hospitalization or death, if the problem is left untreated or the disease progresses.
 
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