Wiki E/M - acute uncomplicated vs acute with systemic symptoms

[SuFra21]

The providers in my Pedi office are asking for more clarification on acute uncomplicated problem vs acute problem with systemic symptoms. We are coding for common pedi ailments like sore throat, uti, uri, diarrhea or ear infection. The most common problem they question is sore throat with fever and a negative strep test. They feel that the fever makes this acute with systemic symptoms. In the visit they are also discussing a differential diagnosis and the potential for ordering labs if the problem does not resolve in the given time frame. I agree with them on the systemic symptoms and that could potentially be coded as a level 4 depending on their documentation, age, and chronic conditions of the patient. Do you agree that these issues could be go either way depending on the specific patient or is the line more difinitive on these problems? I would say the ear infection problem is acute uncomplicated since it is typically straightforward once the ears are checked on exam.

Please let me know your thoughts! Any help would be great!!
Sue

 

[rthomas@impcna.com]

I attached 2 different documents. One is from AAPC and the other is from AMA. I use the AAPC one as a quick reference but the AMA article goes in detail.

 

[Jenharter81]

This has been a discussion around our office as well, and the best way I found to think about it to think about the patient's risk of morbidity (I'm sorry I can't find what site I found this on to give credit)
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, 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.

This of course can vary from patient to patient - EX: A patient has a fever with classic URI symptoms (as long as there are no other underlying issues) the patient typically would have a low risk for morbidity without treatment. Look at the URI as an acute, uncomplicated illness with the fever as a self-limited problem.

However if the patient has a fever along with a problem that would harm the patient if left untreated, say cellulitis with a fever (sorry I don't have a peds example), then you could consider the fever as a systemic symptom.

I interrupted this to be if the symptom is typical to the disease and treatment is sought to alleviate the issues (and patient would have full recovery without treatment) then it is NOT systemic,
If treatment is sought and the symptoms increase the risk/threat to the patient where they would face increased harm, hospitalization or potentially death without treatment, then symptom would be considered systemic.

Hope that helps (and if anyone thinks I'm off on this, please let me know

 

[blaymon]

The key sentence in the definition of "Acute Illness With Systemic Symptoms" is; 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. I read that as a viral illness and the provider is NOT going to prescribe antibiotics or other prescription medication. The provider is basically informing the patient to take OTC medications to alleviate symptoms. I agree with the providers, if a pediatric patient has a temp of 102 and an acute otitis media, the provider will treat with antibiotics to lessen the risk of complications. This is from the AMA Coding Toolkit- look at Vignette #5 (www.ama-assn.org/system/files/steps-forward-documentation-coding-toolkit.pdf) which has a similar scenario (a pediatric patient with a fever and otitis media). They chose a level 4 based on systemic symptoms and prescription management.