Consider CPT® definitions of systemic symptoms for precise coding.
When the AMA revised the office and outpatient evaluation and management (E/M) CPT® codes back in 2021, there were few complaints from the coding community. The new codes, and the guidelines that accompanied them, are far easier to follow and implement than the 1995 and 1997 guidelines that preceded them.
But as user-friendly as they are, they aren’t entirely black and white. Despite further tweaking in the years that followed, 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) still create their fair share of headaches and confusion. In providing much-needed flexibility, the revised codes and their guidelines created gray areas that still require considerable coding judgement skills to navigate.
One such area occurs in the interpretation of the terms “acute illness with systemic symptoms,” especially when applied to a common illness such as strep throat. Here’s why this is a problem and why it matters when you calculate levels for your office/outpatient E/M visits.
Begin by Learning the CPT® Definition
According to CPT®, an acute illness with systemic symptoms is “an illness that causes systemic symptoms and has a high risk of morbidity without treatment.”
But the CPT® definition doesn’t stop there. It goes on to make a distinction between systemic symptoms and “systemic general symptoms, such as fever, body aches, or fatigue.” When these occur in a minor illness, CPT® tells you to regard the condition as a “self-limited or minor problem or acute, uncomplicated illness or injury.”
Then, Understand How This Relates to E/M Level
One look at the Levels of Medical Decision Making (MDM) table in the CPT® code book shows you how making the correct decision above affects the overall level of service you can assign.
According to the table, if the provider classifies the acute illness with systemic symptoms as a self-limited or minor problem or an acute, uncomplicated illness or injury, then the condition only rises to the low level of MDM in the Number and Complexity of Problems element of MDM. However, if the provider documents that the condition has a high risk of morbidity without treatment, the Number and Complexity of Problems element of MDM for the condition rises at least as high as the moderate level and could, if the condition “poses a threat to life or bodily function,” rise to the high level of MDM for the problem element.
Next, Understand the Nature of the Condition
So, does strep throat represent a low, moderate, or even a high problem element of MDM? To determine that, you first need to look at the range of clinical information on the condition. But even here, the waters are muddied.
We know that the condition is caused by a bacterial infection. We also know that most bacterial infections, strep throat included, will resolve themselves after a few days without treatment. However, because untreated strep throat can lead to serious complications, including the sometimes fatal rheumatic fever, consensus opinion within the medical community is that treatment with antibiotics is the most prudent course of action.
This would suggest the condition rises to moderate MDM at the problem level element which, in combination with one of the other two MDM elements, could then lead to justifying a level 4 office/outpatient E/M.
But Don’t Leap to Conclusions
However, “there are lots of things that, without intervention, could become bigger problems. Just because something could turn bad doesn’t make it a level 4,” according to Samuel “Le” Church, MD, MPH, CPC, CRC, FAAFP, core faculty family medicine residency at Northeast Georgia Health System and member of the CPT® Editorial Panel.
Similarly, “even with systemic symptoms, I am not a big fan of billing a level 4 for strep throat. I would argue that it isn’t the actual strep throat that has a high risk of mortality without treatment; it is the complications that can arise from not being treated,” according to Donna Walaszek, CCS-P, Northampton Area Pediatrics, Northampton Massachusetts.
In other words, “generally, if untreated, strep goes away on its own. Treatment is to prevent it from going to the heart, which is rheumatic fever,” according to Church. This would suggest strep throat more readily aligns itself with the CPT® definition of a self-limited or minor problem or acute, uncomplicated illness or injury, meaning the condition only rises to the low level of MDM for the problem element.
And Always Consider the Context
But under the right circumstances, strep throat can be viewed as a moderate, or level 4, visit. For one, the Risk element of MDM rises to moderate if the provider prescribes antibiotics as a treatment.
But the presence of symptoms such as fever, headache, abdominal pain, vomiting, or a rash don’t automatically qualify as systemic, allowing the Problem element level of MDM to rise to moderate as well. These symptoms all fit the CPT® definition of systemic general symptoms which, as already established, more closely align with a self-limited or minor problem or acute, uncomplicated illness or injury and, as such, only rise to a low level of Problem element MDM.
It is only when these symptoms pose a threat to a patient who is immunocompromised due to a chronic condition — for example, “the level 4 complication might be if you’ve got a patient with type 1 diabetes who develops strep,” according to Church — that you can legitimately bump the Problem element up to the moderate level of MDM.
In other words, when the patient’s history includes a documented comorbidity, you may have a clinical scenario in which reporting a strep throat encounter as a level 4 is appropriate. But “you would need to go back to the provider and ask if they could give you the data that helps support how risky the condition is for that patient. There are other examples, such as the management of a COVID-19 infection, where documentation of a high risk of progression to severe morbidity without treatment based on co-morbid factors, such as age or COPD [chronic obstructive pulmonary disease], clearly moves the complexity to moderate,” Church explains. Or, as Walaszek puts it, you’ll need “significant documentation supporting something beyond just a rash, fever, or stomachache.”
So, what’s the takeaway in all of this? Never assume that a condition automatically equates to a certain level of office/outpatient E/M. Nothing is ever automatic in E/M coding, which means you must use caution with “always” or “never” statements.
Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
