If a established patient presents with ear pain and the provider prescribes antibiotics does this automatically make it a Level 4 (99214). If this is the only reason they are being seen and don't have an comorbidities than couldn't they code a 99213?
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Wiki E/m coding
- Thread starter DIVINE50
- Start date
With the exception of the time component of the E&M leveling, there is nothing that automatically makes it one level or another. 
If the patient is established and comes in with a new presenting problem of ear pain and is prescribed antibiotics for the plan of care...then the MDM would level at a Moderate since the presenting problem is new and the level or risk is moderate due to the prescription.
However for an overall leveling of 99213 vs 99214 the history and the exam would need to be leveled for a full picture. So additional leveling would need to be completed for the overall E&M code.
If the patient is established and comes in with a new presenting problem of ear pain and is prescribed antibiotics for the plan of care...then the MDM would level at a Moderate since the presenting problem is new and the level or risk is moderate due to the prescription.
However for an overall leveling of 99213 vs 99214 the history and the exam would need to be leveled for a full picture. So additional leveling would need to be completed for the overall E&M code.