Wiki Recurrent condition- acute complicated illness vs acute uncomplicated illness

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Rajapandi2019

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Hi, When patient came for recurrent pilonidal cyst (symptom-pain) or recurrent UTI (symptom-pain, dysura) or recurrent sinusitis (facial pressure, post nasal drip) with related symptoms, Can we consider this acute complicated illness? generally those are go with acute uncomplicated illness. I stuck with the word recurrent. Kindly clarify.

Chief Complaint
As cyst on lower back he had surgery on 4 years ago, Came back two days ago and popped but didn't drain completely. Painful
History of Present Illness
The patient presents with a recurrent infected pilonidal cyst. It opened some and drained on Saturday. He had surgery 4 years ago for the same thing and it was good until 2 or 3 months ago when he had a recurrence. It opened and drained at that time. No fever. No nausea or vomiting. No systemic symptoms. No treatment has been tried. ROS all other systems negative.
Physical Examination
General: Alert and oriented, No acute distress.
Respiratory: Respirations are non-labored.
Cardiovascular: Normal rate.
Integumentary: Warm, Dry, Pink, No rash, The patient's gluteal cleft has a 1 cm inflammatory cystic structure with some mild purulent drainage. There appears to be a sinus track centrally. Tender in the local area..
Assessment
The patient has a recurrent pilonidal cyst with inflammation and infection. After patient's consent regarding the risk of bleeding infection and recurrence we cleaned the area in the normal fashion and use 11 blade scalpel to incise and drain some purulent debris and apply a 4 x 4 dressing. We will place him on Augmentin twice daily for 10 days and have him do soaks couple times a day. I like to have him see general surgery in Mason City who saw him 4 years ago and did a procedure for the same. Follow-up as needed. Prescribed amoxicillin-clavulanate 875 mg-125 mg oral tablet
 
I would not consider any of these to be complicated illnesses.

here are definitions from the AMA:

"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 selflimited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness."

"Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care:
A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting."

"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. "

I hope this helps.
 
lgardner said:
I would not consider any of these to be complicated illnesses.

here are definitions from the AMA:

"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 selflimited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness."

"Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care:
A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting."

"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. "

I hope this helps.
Click to expand...
Thank you! It could help.
 
Hi Raja
The provider needs to use the following terms in his or her documentation of any illness or symptoms to help coders assign the proper dx code. The words in documentation which supports dx codes are such as: chronic, dx I25.82 H65.411,M1A.02,G89.2 I50.22 I96.1 acute H66.011, g89.1, S75.02 ,dx I30..0 J96.0 N00 remissiondxF30,4 F10.21 , recurrent, (depression F33 ,N02.6 or ongoing pain (dx G89.29). There are certain dx that are coded chronic vs acute in all types of diseases. I tried to list some examples in the above sentence. If none listed can use unspecific dx unless provider gives you clues in documentation of more details in describing the diagnosis. There are different levels/stages of diseases hopefully he or she shall be clear about that factor. As examples differ levels or stages of illness such as: HTN, DM, Hemorrhoids, Diarrhea, Sinusitis, Anemia,Depression,Arthritis, Fractures, Cardiac , Etc.
I hope this data helps you too
Lady T
 
Recurrent: 1. occurring often or repeatedly.

Just because the condition is recurrent doesn't give you the information you need to make a determination about the illness or problem.
You would use the definitions from the example @lgardner gave you above to determine the number and complexity of the problems that are addressed at the encounter. It always comes back to the definitions.

From your example above, I highlighted and underlined the key terms to help you decide.

Chief Complaint
As cyst on lower back he had surgery on 4 years ago, Came back two days ago and popped but didn't drain completely. Painful
History of Present Illness
The patient presents with a recurrent infected pilonidal cyst. It opened some and drained on Saturday. He had surgery 4 years ago for the same thing and it was good until 2 or 3 months ago when he had a recurrence. It opened and drained at that time. No fever. No nausea or vomiting. No systemic symptoms. No treatment has been tried. ROS all other systems negative.
Physical Examination
General: Alert and oriented, No acute distress.
Respiratory: Respirations are non-labored.
Cardiovascular: Normal rate.
Integumentary: Warm, Dry, Pink, No rash, The patient's gluteal cleft has a 1 cm inflammatory cystic structure with some mild purulent drainage. There appears to be a sinus track centrally. Tender in the local area..
Assessment
The patient has a recurrent pilonidal cyst with inflammation and infection. After patient's consent regarding the risk of bleeding infection and recurrence we cleaned the area in the normal fashion and use 11 blade scalpel to incise and drain some purulent debris and apply a 4 x 4 dressing. We will place him on Augmentin twice daily for 10 days and have him do soaks couple times a day. I like to have him see general surgery in Mason City who saw him 4 years ago and did a procedure for the same. Follow-up as needed. Prescribed amoxicillin-clavulanate 875 mg-125 mg oral tablet


From this, you would look at the definitions here to decide: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Minimal problem - No
Self-limited or minor problem - No
Stable, chronic illness - No
Acute, uncomplicated illness or injury - Yes: Acute, uncomplicated illness or injury: A recent or new short-term problem (infected pilonidal cyst) with low risk of morbidity for which treatment (I&D) (antibiotics) 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, uncomplicated illness or injury requiring hospital inpatient or observation level care - No
Stable, acute illness - No
Chronic illness with exacerbation, progression, or side effects of treatment - No
Undiagnosed new problem with uncertain prognosis - No
Acute illness with systemic symptoms - No
Acute, complicated injury - No
Chronic illness with severe exacerbation, progression, or side effects of treatment - No
Acute or chronic illness or injury that poses a threat to life or bodily function - No
 
amyjph said:
Recurrent: 1. occurring often or repeatedly.

Just because the condition is recurrent doesn't give you the information you need to make a determination about the illness or problem.
You would use the definitions from the example @lgardner gave you above to determine the number and complexity of the problems that are addressed at the encounter. It always comes back to the definitions.

From your example above, I highlighted and underlined the key terms to help you decide.

Chief Complaint
As cyst on lower back he had surgery on 4 years ago, Came back two days ago and popped but didn't drain completely. Painful
History of Present Illness
The patient presents with a recurrent infected pilonidal cyst. It opened some and drained on Saturday. He had surgery 4 years ago for the same thing and it was good until 2 or 3 months ago when he had a recurrence. It opened and drained at that time. No fever. No nausea or vomiting. No systemic symptoms. No treatment has been tried. ROS all other systems negative.
Physical Examination
General: Alert and oriented, No acute distress.
Respiratory: Respirations are non-labored.
Cardiovascular: Normal rate.
Integumentary: Warm, Dry, Pink, No rash, The patient's gluteal cleft has a 1 cm inflammatory cystic structure with some mild purulent drainage. There appears to be a sinus track centrally. Tender in the local area..
Assessment
The patient has a recurrent pilonidal cyst with inflammation and infection. After patient's consent regarding the risk of bleeding infection and recurrence we cleaned the area in the normal fashion and use 11 blade scalpel to incise and drain some purulent debris and apply a 4 x 4 dressing. We will place him on Augmentin twice daily for 10 days and have him do soaks couple times a day. I like to have him see general surgery in Mason City who saw him 4 years ago and did a procedure for the same. Follow-up as needed. Prescribed amoxicillin-clavulanate 875 mg-125 mg oral tablet


From this, you would look at the definitions here to decide: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Minimal problem - No
Self-limited or minor problem - No
Stable, chronic illness - No
Acute, uncomplicated illness or injury - Yes: Acute, uncomplicated illness or injury: A recent or new short-term problem (infected pilonidal cyst) with low risk of morbidity for which treatment (I&D) (antibiotics) 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, uncomplicated illness or injury requiring hospital inpatient or observation level care - No
Stable, acute illness - No
Chronic illness with exacerbation, progression, or side effects of treatment - No
Undiagnosed new problem with uncertain prognosis - No
Acute illness with systemic symptoms - No
Acute, complicated injury - No
Chronic illness with severe exacerbation, progression, or side effects of treatment - No
Acute or chronic illness or injury that poses a threat to life or bodily function - No
Click to expand...
Thanks a lot!!! I learnt more from the given answers.
 
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