October 12, 2021 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
2021 AMA guidance indicates that a general systemic symptom such as fever should not be considered a systemic system, but not all fevers fall in this category. The question typically posed is: what is the “magic” range that identifies it as no longer of general nature? There is no range, there is no age, and there is no guidance. This criterion is based on what everything is always based on – documentation!
If the documentation indicates that the patient has had a mild fever reduced by OTC medication, and in the office, they had low to no fever, the child was active, and the provider told the mom to continue supportive care, this encounter does NOT appear to infer fever is systemic. However, if the fever is not resolving and the child is lethargic in the office, and the mom is told to alternate the Tylenol and Advil, consider baths as needed to lower the body temperature, and to report to the ER for any concerns of seizures or continued elevation of fever, there is now an inference of a high-grade fever that is beyond a general fever that could represent systemic symptomology. Therefore, the whole answer is- it comes back to the documentation as always.
