2021 CPT E/M Guideline Definitions for Acute and Chronic Illnesses
Acute, uncomplicated illness or injury
- The problem is recent and short-term
- There is little to no risk of mortality with treatment
- Full recovery without functional impairment is expected
- The problem may be self-limited or minor, but it is not resolving in line with a definite and prescribed course
- Examples: Cystitis, Allergic rhinitis, Simple sprain
Acute illness with systemic symptoms
- The illness causes systemic symptoms, which may be general or single system
- There is a high risk of morbidity without treatment
- For a minor illness with systemic symptoms like fever or fatigue, consider acute, uncomplicated or self-limited/minor instead
- Examples: Pyelonephritis, Pneumonitis, Colitis
Acute, complicated injury
- Treatment requires evaluation of body systems that are not part of the injured organ, the injury is extensive, there are multiple treatment options, or there is a risk of morbidity with treatment
- Example: Head injury with brief loss of consciousness
Stable, chronic illness
- This type of problem is expected to last at least a year or until the patient’s death
- A change in stage or severity does not change whether a condition is chronic
- The patient’s treatment goals determine whether the illness is stable. A patient who has not achieved their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function
- The risk of morbidity is significant without treatment
- Examples: Well-controlled hypertension, Non-insulin dependent diabetes, Cataract, Benign prostatic hyperplasia, NOT stable: Asymptomatic but persistently poorly controlled blood pressure (pressures don’t change), with a treatment goal of better control
Chronic illness with exacerbation, progression, or side effects of treatment
- The chronic illness is getting worse, is not well controlled, or is progressing “with an intent to control progression”
- The condition requires additional care or treatment of the side effects
- Hospital level of care is not required
- No examples given by CPT guidelines
Chronic illness with severe exacerbation, progression, or side effects of treatment
- There is a significant risk of morbidity
- The patient may require hospital care
- No examples given by CPT guidelines
Acute or chronic illness or injury that poses a threat to life or bodily function
- There is a near-term threat to life or bodily function without treatment
- An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment may be involved
- Examples: Acute myocardial infarction, Pulmonary embolus, Severe respiratory distress, Progressive severe rheumatoid arthritis, Psychiatric illness with potential threat to self or others, Peritonitis, Acute renal failure, Abrupt change in neurologic status
