25 year old established patient, 17 weeks pregnant, fever, productive cough, sinus drainage, congestion, sore throat, SOB, and bilateral earache.
Duration: 5 days
Negative for influenza
Diagnosis: Acute Bronchitis, Acute suppurative otitis media NOS
MD performed nebulizer Tx in office (94640), and prescribed cefprozil 500mg
Also advised to get lots of fluids, rest, tylenol for fevers and discomfort.
He documented a comprehensive history and exam, and moderate MDM by my count (he almost always has either a detailed or comp H&P - his biggest trouble area is matching his work to the medical necessity of the presenting problem), and he scored this as a 99214 - was this visit severe enough to warrant a level IV exam? (Or even level V, for that matter?)
I've read the examples in the CPT about 100 times, now, and none of them are really similar enough to this to fit. Any thoughts?
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