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E/M Coding ...

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    Just want to double check with everyone to make sure I'm handling the following coding correctly. For this example I would code as a 99202, guidelines 1995. But with the oral decadron given and a prescription would this change to a level 3?

    CC: Ear pain for 3 days
    27 year old male, new patient presents with earache ongoing for 3 days. Ear does have slight drainage and tender to touch. Pt denies headache, nausea, cough, discomfort of eyes along with no discomfort of throat.

    Medical History: Knee surgery 2007
    Family: Mother heart disease, hypertension
    Social: Occasional alcohol

    Constitutional: 100 body temp
    Pt looks state age, well groomed
    Eyes: clear, bright,
    ENMT: ear is tender, some drainage, mildly swollen, red.
    Respiratory: breathing is well, no crackles, etc...
    Integumentary: skin is warm to touch

    Due to the drainage, tenderness and slight swelling of the ear did give oral decadron in office. Will prescribe ofloxacin. Go to emergency department if symptoms worsen
    Last edited by Worxs43; 09-23-2018 at 11:04 PM. Reason: addtl info

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