EM in ED Question

Casillas

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A patient is seen in the ED with a chief complaint of sore throat. The physician documents a detailed HX. The physical exanimation is comprehensive. The physician orders a rapid strep that is negative. The physician's clinical impression is pharyngitis. However the physician writes a prescription for an oral antibiotic; this makes the highest level of risk a moderate. When we compute the level we come up with a 99283 or 99284. This seems to us too high a level for a sore throat. It seems to us that a risk level of low is more appropriate despite the prescription drug management. This would level out to 99282. Any thoughts?
 

Mojo

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We would code this visit 99283, moderate MDM for a new problem, no additional workup planned with prescription drug management. The documentation for this type of presenting problem usually warrants an EPF hx or exam, but I would never complain about thorough documentation. :)
 
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