A new patient presents to our office. The diagnoses are acute pharyngitis and a viral infection. The provider placed the patient on two differant antibiotics for these condtions. The provider performed a comprehensive history and exam which I get using both the 95 and 97 guidelines. This codes out to a 99204. All three key components meet here.
Now here is my dilema....I feel the provider overdocumented the exam here based on the chief complaint. The chief complaint was cough, fever, headache, nasal congestion/drainage, and sore throat.
I feel this should be downcoded to a level three (99203), but I know this provider will feel that the 99204 is appropriate based on the facts that the key components meet here and since this is a new patient a more through exam and history was required.
I would appreciate any and all thoughts or opinions here.
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