Wiki Help! uncomplicated or systemic

[stephanie2015]

I code for Neurosurgeons, patients come in with low back pain, with pain radiating down both legs for 6 months. Dr. gives dx of lumbar radiculopathy. Were sending patient to PT and then back to office in 6 wks with updated films/mri. Would this fall under the problem category of Acute w/ systemic symptoms since pain is in back but going to down legs into foot or would it fall under acute uncomplicated? Or what would you have it fall under?

 

[amyjph]

It's more likely chronic. For example - Chronic illness with exacerbation, progression, or side effects of treatment (if not getting better).
Because it's probably stenosis. Unless a disc herniation from some accident or something but that is rare and would be treated right away (usually).
It depends on the LBP cause, timeline, was it due to injury/accident or has it been long term?
When I think of systemic symptoms it's more like cough, fatigue, loss of appetite, unintended weight loss, fever, etc.

Have you asked the provider their thoughts?

 

[xXxPARAGONxXx]

I code for Neurosurgeons, patients come in with low back pain, with pain radiating down both legs for 6 months. Dr. gives dx of lumbar radiculopathy. Were sending patient to PT and then back to office in 6 wks with updated films/mri. Would this fall under the problem category of Acute w/ systemic symptoms since pain is in back but going to down legs into foot or would it fall under acute uncomplicated? Or what would you have it fall under?

Certainly not systemic. Systemic means that it involves the entire body. The provider should be documenting chronic versus acute in the notes especially after re-evaluation of the patient after completing treatment modalities (e.g., physical therapy). However, after 3 months, pain is usually considered chronic.[1]

Footnotes
[1] https://journals.lww.com/pain/fulltext/2022/02000/classification_of_chronic_pain_for_the.29.aspx: “Chronic pain is defined as pain that lasts or recurs for longer than 3 months.”