Professional Documents
Culture Documents
Definitions:
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)
Examples:
12-year-old male patient presents with right wrist pain from bicycle fall. No fracture
seen on x-ray. Diagnosed with right wrist sprain.
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.
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.
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 1 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.