SuFra21
Contributor
The providers in my Pedi office are asking for more clarification on acute uncomplicated problem vs acute problem with systemic symptoms. We are coding for common pedi ailments like sore throat, uti, uri, diarrhea or ear infection. The most common problem they question is sore throat with fever and a negative strep test. They feel that the fever makes this acute with systemic symptoms. In the visit they are also discussing a differential diagnosis and the potential for ordering labs if the problem does not resolve in the given time frame. I agree with them on the systemic symptoms and that could potentially be coded as a level 4 depending on their documentation, age, and chronic conditions of the patient. Do you agree that these issues could be go either way depending on the specific patient or is the line more difinitive on these problems? I would say the ear infection problem is acute uncomplicated since it is typically straightforward once the ears are checked on exam.
Please let me know your thoughts! Any help would be great!!
Sue
Please let me know your thoughts! Any help would be great!!
Sue