Acute, uncomplicated vs. acute with systemic symptoms

Question:

When using the E/M guidelines, is the problem an  an acute, uncomplicated illness or an acute illness with systemic symptoms?

Answer:

Let’s start with the CPT definitions, from the  CPT^® Professional edition.

Acute, uncomplicated illness	Acute illness with systemic symptoms
From CPT®: 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 self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness	From CPT®: 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, shorten the course of illness or to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general, but may be single system.
From CPT®: Examples may include cystitis, allergic rhinitis, or a simple sprain.	From CPT®: Examples may include pyelonephritis, pneumonitis, or colitis.
Little to no risk of mortality	High risk of morbidity without treatment
Full recovery without functional impairment	If treating systemic general symptoms such as fever, body aches or fatigue see: “self-limited or minor” or “acute uncomplicated.”
Other examples: Otitis, URI, UTI, diarrhea	Patient has symptoms in other body areas/organ systems than condition
Fever, body aches, fatigue in the conditions  listed above do not constitute an acute illness with systemic symptoms	SOB, cough, fatigue, loss of appetite, unintended weight loss in a patient with pneumonitis is an example of acute illness with systemic symptoms

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.

And, read again the sentence (not the most straightforward sentence ever written) “For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’”  That is, fever  or fatigue with a URI or otitis do not qualify as an acute illness with systemic symptoms.