I keep hearing different things for ear infection visits. I code for Pediatricians who see a lot of patients with OM. Would you ever code a visit with the diagnosis of OM as a 99214 or due to the nature of the presenting problem, would this always be a 99213?
Here is one example - what level do you get for the following documentation? (this is a 14 month old and the only other time this provider saw the patient it was for a well child check. No complaints.)
Thanks!
SUBJECTIVE:
History of Present Illness:
Accompanied By: Father.
Symptom(s): Fever. Fussiness. Rhinorrhea. Cough. No emesis. No
diarrhea.
Fever: Duration: 3 days.
Max. temp. 101 degrees F.
Fussiness: Duration: Last night.
Rhinorrhea: Duration: 5 days.
Cough: Duration: 5 days.
Acute Medications Used / Exposures:
Acetaminophen.
Past / Family History:
ADR's, Medications, and Problem List reviewed and updated today in the EMR.
OBJECTIVE:
Vital Signs taken today were reviewed on the flowsheet in EMR.
General: alert but uncooperative during exam.
Eyes: no injection or drainage.
Ears: left tympanic membrane normal, right tympanic membrane erythematous
with purulent effusion
Nose: mild congestion
Oropharynx: moist mucus membranes without ulcerations; tonsils symmetric
without erythema or exudate.
Neck: supple without adenopathy or goiter.
Chest: clear to auscultation; normal effort.
Cardiac: regular rate without murmur.
Labs/Studies Done Today
No labs done.
ASSESSMENT:
Acute Right Otitis Media.
PLAN:
Symptomatic care. Encourage fluids and rest. Acetaminophen, ibuprofen, or
other OTC medications only as directed on package. RTC PRN if fevers are
difficult to control, poor fluid intake, or progressive worsening of
symptoms.
Azithromycin (Zithromax) 10 mg/kg today, then 5 mg/kg daily for 4 days.
Here is one example - what level do you get for the following documentation? (this is a 14 month old and the only other time this provider saw the patient it was for a well child check. No complaints.)
Thanks!
SUBJECTIVE:
History of Present Illness:
Accompanied By: Father.
Symptom(s): Fever. Fussiness. Rhinorrhea. Cough. No emesis. No
diarrhea.
Fever: Duration: 3 days.
Max. temp. 101 degrees F.
Fussiness: Duration: Last night.
Rhinorrhea: Duration: 5 days.
Cough: Duration: 5 days.
Acute Medications Used / Exposures:
Acetaminophen.
Past / Family History:
ADR's, Medications, and Problem List reviewed and updated today in the EMR.
OBJECTIVE:
Vital Signs taken today were reviewed on the flowsheet in EMR.
General: alert but uncooperative during exam.
Eyes: no injection or drainage.
Ears: left tympanic membrane normal, right tympanic membrane erythematous
with purulent effusion
Nose: mild congestion
Oropharynx: moist mucus membranes without ulcerations; tonsils symmetric
without erythema or exudate.
Neck: supple without adenopathy or goiter.
Chest: clear to auscultation; normal effort.
Cardiac: regular rate without murmur.
Labs/Studies Done Today
No labs done.
ASSESSMENT:
Acute Right Otitis Media.
PLAN:
Symptomatic care. Encourage fluids and rest. Acetaminophen, ibuprofen, or
other OTC medications only as directed on package. RTC PRN if fevers are
difficult to control, poor fluid intake, or progressive worsening of
symptoms.
Azithromycin (Zithromax) 10 mg/kg today, then 5 mg/kg daily for 4 days.