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

Q: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?

A: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.

Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.