E/M Coding .

Worxs43

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Good Evening,

Need anyone's insight regarding presenting problems. There was insight that I had received stating that a presenting problem that is less than 72 hours with a prescription being prescribed would be a 99203 instead of a 99202. Is this true? The following example I usually would level as a 99202 regardless of time I see the plan of care being straightforward.

Guidelines 1995

CC: Ear pain for 3 days + sore throat
27 year old male, new patient presents with earache ongoing for 3 days. Ear does have slight drainage, tender to touch and sore throat. Pt denies headache, nausea, cough, no discomfort of eyes.

Medical History: Knee surgery 2007
Family: Mother heart disease, hypertension
Social: Occasional alcohol

Constitutional: 100 body temp
Pt looks state age, well groomed
Eyes: clear, bright,
ENMT: ear is tender, some drainage, mildly swollen, red
throat is somewhat sore
Respiratory: breathing is well, no crackles, etc...
Integumentary: skin is warm to touch

Found through examining the ear does have mild drainage, tender and red. For the thoat performed a strep test which was negative. Due to the drainage, tenderness and slight swelling of the ear will prescribe ofloxacin. As for the sore thoat recommended warm salt water gargles and Chloraseptic. Go to emergency department if symptoms worsen
 
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