baport12
New
Utilizing the 2021 New E&M Outpatient Coding Guidelines, Please code this E&M
Patient 1: This established 2-year-old female presents with cough, nasal discharge, and fever. Cough onset was one week ago, has gotten worse over time, and has been nonproductive. Nothing relieves the cough as yet. Maximum fever temperature was 102 degrees Fahrenheit for three days, but it has resolved. Acetaminophen helps.
Her parents both smoke in the home. The patient has no known allergies. Patient has a history of otitis media.
ROS: Constitutional positive for fever, HEENT positive for nasal congestion and rhinorrhea, respiratory positive for cough.
Exam: Constitutional: Patient appears well-nourished, happy, and well-developed, with no distress noted. Ears: Right ear shows a normal tympanic membrane; left ear shows tympanic membrane erythematous. Nose/mouth/throat: Nose and throat are clear, mucous membranes moist, and no oral lesions are noted. Teeth and gums are normal for age. Lymphatic: No abnormal cervical, supraclavicular or axillary adenopathy is noted. Respiratory: Normal to inspection. Lungs clear to auscultation bilaterally. Normal respiratory effort is noted. Cardiovascular: Regular rate and rhythm, with no murmurs. Abdomen: Soft, non-tender, and non-distended.
Assessment: Acute suppurative otitis media without spontaneous rupture of ear drum, left ear (H66.002). Prescribing amoxicillin oral suspension to be taken twice a day for 10 days.
Patient 1: This established 2-year-old female presents with cough, nasal discharge, and fever. Cough onset was one week ago, has gotten worse over time, and has been nonproductive. Nothing relieves the cough as yet. Maximum fever temperature was 102 degrees Fahrenheit for three days, but it has resolved. Acetaminophen helps.
Her parents both smoke in the home. The patient has no known allergies. Patient has a history of otitis media.
ROS: Constitutional positive for fever, HEENT positive for nasal congestion and rhinorrhea, respiratory positive for cough.
Exam: Constitutional: Patient appears well-nourished, happy, and well-developed, with no distress noted. Ears: Right ear shows a normal tympanic membrane; left ear shows tympanic membrane erythematous. Nose/mouth/throat: Nose and throat are clear, mucous membranes moist, and no oral lesions are noted. Teeth and gums are normal for age. Lymphatic: No abnormal cervical, supraclavicular or axillary adenopathy is noted. Respiratory: Normal to inspection. Lungs clear to auscultation bilaterally. Normal respiratory effort is noted. Cardiovascular: Regular rate and rhythm, with no murmurs. Abdomen: Soft, non-tender, and non-distended.
Assessment: Acute suppurative otitis media without spontaneous rupture of ear drum, left ear (H66.002). Prescribing amoxicillin oral suspension to be taken twice a day for 10 days.