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MDM – Coding acute, uncomplicated vs. acute with systemic symptoms
What is the difference between an acute, uncomplicated illness and an acute illness 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.
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