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Wiki 99213 or 99214?

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avrodriguez

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7 y/o kid comes complaining of fever and cough, physical exam normal, besides nasal congestion, had strep and flu test done both negative, final diagnosis is URI kid was given a prescription for cough medicine ( not over the counter ) and told to return if fever worsen any new symptom, or not resolved in 3 days.
is this a 99213 or 99214? and why?
 
There is not enough information here. This could even possibly be 99212.
E/M leveling is done by 3 elements - history, exam & MDM. New requires all 3. Established requires 2/3.
With the information here, I would consider MDM level 4, assuming this is a new problem. New problem, additional workup; risk level 4 for acute illness with systemic symptoms. Depending on the level of history and exam, this could be 99212, 99213 or 99214.
 
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