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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

 

Resources:

https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx#OfficeOutpatientEMCodingBefore2021

Samantha Mason, CPC

Written by Samantha Mason, CPC

Healthcare Coding & Consulting Services

(a.k.a. HCCS)

This blog is an extension of our uncompromising values and dedication to our clients, staff, and the HIM industry as a whole.

 

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