Should this be coded a 99213 or 99214 based on documentation?

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mskitaly09

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The provider is stating this should be a level 4. I based it on acute-uncomplicated problems, 2 ordered labs, and prescription drug management, which is a level 3. Pt tested positive for Flu A. Or are the problems acute w/systemic symptoms?


Chief Complaints:
1. mother is present, monday developed upset stomach/Diarrhea, tuesday no symptom and then developed these symptoms again when he went back to school, mother thinks it may be related to too much spicy/acidic food.

HPI:
Analysis of Problem:

Patient presents today with intermittent abdominal pain and diarrhea since Tuesday. HA started today. Denies fever, cough, sore throat, vomiting, decreased appetite.

Assessment:
Assessment:
1. Acute streptococcal pharyngitis - J02.0 (Primary)
2. Loose stools - R19.5
3. Influenza A - J10.1


Plan:
Treatment:
1. Acute streptococcal pharyngitis
Start Cefdinir Suspension Reconstituted, 250 MG/5ML, 9.7 mL, Orally, daily, 10 days, 97 ML, Refills 0 .
Clinical Notes: Can take cefdinir according to mom. Rest. Out of school tomorrow. Push fluids. Change toothbrush on Saturday. RTC if not improving.
2. Loose stools
LAB: Rapid Strep (Collection Date & Time - 12/18/2025) positive
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3. Influenza A
Clinical Notes: Supportive care. Push fluids. Rest. Pl

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Value​
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Strep A​
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 LAB: Flu + SARS Antigen FIA (Collection Date & Time - 12/18/2025) Flu A pos/ Bneg, SARS neg[/td]
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Acute uncomplicated. There is nothing in that note that shows acute, systemic.


Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.
 
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