E/M Coding ...


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Just want to double check with everyone to make sure I'm handling the following coding correctly. For this example I would code as a 99202, guidelines 1995. But with the oral decadron given and a prescription would this change to a level 3?

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

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.
Respiratory: breathing is well, no crackles, etc...
Integumentary: skin is warm to touch

Due to the drainage, tenderness and slight swelling of the ear did give oral decadron in office. Will prescribe ofloxacin. Go to emergency department if symptoms worsen
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