Acute Uncomplicated vs Complicated Illness or Injury

One of the most difficult determinations of Number and Complexity of Problems Addressed is complicated vs uncomplicated.

When selecting Number and Complexity of Problems Addressed, the complication of treatment required should not be considered. The Risk of Complications of Patient Management is where the treatment options are considered in code selection.

Definitions

The AMA defines an acute uncomplicated illness or injury as a "recent or new short-term problem with low risk of morbidity." A full recovery is expected without residual functionality impairment. This could also be a self-limited or minor condition showing no improvement with prescribed course of treatment (e.g., cystitis, allergic rhinitis, or a simple sprain).

The AMA defines an acute complicated illness or injury as "an injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity." Some examples are multiple injuries, fractures requiring cardiovascular and/or neurovascular evaluations, and/or multiple treatment options are available and must be reviewed to determine appropriate care (e.g., head injury with brief loss of consciousness).

Example of Injury 

The American Academy of Orthopaedic Surgery defines an open fracture as "the bone breaks in such a way that bone fragments stick out through the skin, or a wound penetrates down to the broken bone, the fracture is called an 'open' fracture. This type of fracture is particularly serious because once the skin is broken, infection in both the wound and the bone can occur."

Case Example (Uncomplicated Injury)

12-year-old male patient presents with right wrist pain from bicycle fall. No fracture seen on x-ray. Diagnosed with right wrist sprain.

Case Example (Complicated Injury)

35-year-old female patient presents with left shoulder pain and left hand/finger numbness for 2 months. No known injury. MRI shows nerve damage requiring surgery.

Example of Illness

The American Academy of Family Practice explains the complexity of influenza as "the eighth leading cause of mortality among adults in the United States and results in more than 60,000 deaths annually."

Case Example (Uncomplicated Illness)

28-year-old male patient presents with flu symptoms. Otherwise healthy patient with no other complaints. Flu rapid test positive for Flu A. Patient given prescription for Theraflu and instructed to follow up as needed.

Case Example (Complicated Illness)

46-year-old female patient presents with flu symptoms. BP in office also elevated. Suspect due to illness. Wheezing heard on exam. Flu rapid test positive for Flu A. Patient given a prescription for Theraflu and instructed to follow up in one week.

Documentation should clearly describe the injury/illness and identify the risks and effects on other body systems. Using the words "complex" or "complicated" alone are not sufficient. The note must indicate evaluation of other body systems to determine complication level. Focus should be on the elements that determine complicated vs uncomplicated.

In addition to clear documentation, specific diagnosis coding can help support complexity. An appropriate ICD-10-CM code can indicate type and site of fracture. ICD-10 codes can also be used to indicate other injuries associated with the fracture, as well as the cause. These codes can paint a picture to help explain complexity.

By Jamee Black, CPC, COC, CPMA

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Sources:

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

https://orthoinfo.aaos.org/en/diseases–conditions/fractures-broken-bones/

https://www.aafp.org/afp/2016/1101/p698.html