The surge in respiratory illnesses has led to a common question posed to the AAP Coding Hotline: “Can a fever with COVID-19, respiratory syncytial virus (RSV) or flu (or a combination of the three) be considered an acute illness with systemic symptoms when coding evaluation and management (E/M) visits?”
The answer is not as simple as it may seem.
Of the three elements that make up medical decision-making (MDM), the number and complexity of problems addressed at the encounter seems to be the hardest for coders to determine. While coders need to be well-versed in anatomy and physiology, they usually are not clinically inclined and depend on documentation by the physician or other qualified health care professional (QHP) to guide the choice of E/M codes. Therefore, physicians and QHPs need to document their thought process to support payment of services rendered.
To guide the choice of E/M codes, one needs to review the MDM tables in the Current Procedural Terminology 2023 (CPT) E/M guidelines. While the guidelines contain descriptors that are open to interpretation, definitions are listed to help apply the guidelines and codes.
Acute illness with systemic symptoms is listed under moderate MDM for problems addressed. CPT defines it as “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.” This definition paints a different picture than simply acute illness with systemic symptoms.
CPT further defines morbidity as “a state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.” Under this definition, flu combined with a fever would not fall under acute illness with systemic symptoms.
Even with these definitions, questions remain.
Linda D. Parsi, M.D., M.B.A., FAAP, chair of the AAP Committee on Coding and Nomenclature Editorial Advisory Board, advises looking at the overall context of the patient presentation. RSV and fever in a 5-year-old might not rise to the level of acute illness with systemic symptoms but could in a 2-week-old underweight infant. Clear documentation of the patient’s state during the visit will support accurate code assignment.
Rather than coding acute illness with systemic symptoms, a physician or QHP could select a code based on time. Due to the nature of pediatrics, visits can be time-intensive based on patient population and the difficulties of treating a sick child. Activities included in total time when performed by the physician or QHP include the following:
- preparing to see the patient (e.g., review of tests),
- obtaining and/or reviewing separately obtained history,
- performing a medically appropriate examination and/or evaluation,
- counseling and educating the patient/family/caregiver,
- ordering medications, tests or procedures,
- referring and communicating with other health care professionals (when not separately reported),
- documenting clinical information in the electronic or other health record,
- independently interpreting results (not separately reported),
- communicating results to the patient/family/caregiver and
- care coordination (not separately reported).
When total time and MDM are documented by the physician or QHP, the appropriate code assignment would be whichever results in a higher level of service. The benefit of coding based on time is the option to report prolonged services codes. These codes allow physicians and QHPs to capture additional time spent on a patient’s care before, on or after the date of the face-to-face encounter.
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