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.
 
You are correct, this is a Level 3 visit for an acute, uncomplicated problem. @amyjph posted some excellent resources.

I'll also include a resource from AAPC that I still use occasionally when I'm second guessing myself. I have to attach it because I can't find a link to it.

--
Ryan, CPC
 

Attachments

I was commenting specifically on your question about the COPA. However, this is Low/Mod/Mod so your provider is correct in choosing a 4. You are missing the independent historian credit (Mom since I am assuming this is a minor child).
Acute uncomplicated/2 tests + historian/Prescription = Moderate.
 
amyjph said:
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.
Click to expand...
Thank you for your feedback and sending me the links!
 
rstroup said:
You are correct, this is a Level 3 visit for an acute, uncomplicated problem. @amyjph posted some excellent resources.

I'll also include a resource from AAPC that I still use occasionally when I'm second guessing myself. I have to attach it because I can't find a link to it.

--
Ryan, CPC
Click to expand...
Thank you Ryan for your feedback and resource. Yes I agree Amyjph did provide some excellent resources.
 
amyjph said:
I was commenting specifically on your question about the COPA. However, this is Low/Mod/Mod so your provider is correct in choosing a 4. You are missing the independent historian credit (Mom since I am assuming this is a minor child).
Acute uncomplicated/2 tests + historian/Prescription = Moderate.
Click to expand...
I was told at Healthcons/Auditcons previously with a minor historian the provider must document "mother states, father states, grandmother states, mom reports, etc"....we can't just go off based on the age of the patient to count it towards the historian. I will get more clarification on this, thanks again!
 
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