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

[mskitaly09]

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 [td] ​ [td] ​ [td] ​

3. Influenza A Clinical Notes: Supportive care. Push fluids. Rest. Pl

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Strep A​

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positive​

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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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