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Level of E/M service for child with fever

S

sknirs@yahoo

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7
A 5 year old presents with fever, upon exam he/she was found to have otitis media and and an antibiotic was prescribed. What level of E/M should be billed. Also, can someone please direct me to documentation on E/M codes for children and fevers. Thank you.
 
Well, I can't tell you what "level" because I don't know what the rest of the documentation looks like. (history and exam) or if this is a new or established patient.

I can, however, point you in the right direction for the medical decision making piece.

Otitis media is normally acute, unless specified otherwise. A fever makes it a systemic symptom. This falls under "moderate" on the table of risk. An antibiotic would fall under moderate as well, due to the prescription drug management.

If this is new to the provider, with a moderate risk, it equivilates to a level 4.

If this is established to the provider (assuming it's worsening), with a moderate risk, it would equivilate to a 99213.

Does that help?
 
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