Wednesday, January 18, 2023

MDM – Coding acute, uncomplicated vs. acute with systemic symptoms

When using the 2023 Evaluation and Management (E/M) guidelines, what is the difference between an acute, uncomplicated illness and an acute illness with systemic symptoms?

The 2023 CPT definitions for both sets of guidelines define each of these terms.


If reviewing a note, ask yourself these questions:Is there a high risk or morbidity without treatment? If yes, look at acute illness with systemic symptoms.
  • Is there little to no risk of mortality, and is full recovery without functional impairment expected? Is the condition being treated of a similar acuity to the CPT examples of cystitis and allergic rhinitis? If so, look at acute, uncomplicated illness.


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