Primary Care Coding Alert

One common scenario, two different processes, and a surprising result.

Over the course of this year, we have been looking at the new way you will code office and outpatient evaluation and management (E/M) service levels beginning Jan. 1, 2021. Now it’s time to put that knowledge to the test.

Here is a case study of a common patient complaint.

An established 25-year-old female patient reports with moderate bilateral ear pain extending down the inside of the neck, which she rates as a 5 on a scale of 1-10; and postnasal drip, both of which she has had for a week. The patient denies trauma, tinnitus, or ear discharge, and also denies nausea, vomiting, fever, chills, dizziness, or lightheadedness. She says that her roommate is a cigarette smoker.

In the exam, the provider notes the following: Constitutional: appears non-toxic but is holding her ears. Ears, nose, mouth, and throat: finds postnasal drip and clear ear canals with no perforations or growths but with mild wax buildup and a mild, bilateral inflammation of the tympanic membranes. Respiratory: no crackles or wheezing.Cardiac: regular rate and rhythm with no abnormal sounds. Abdomen: not tender or distended. Skin: no rash.

The provider diagnoses the patient with bilateral otitis media and postnasal drip. She prescribes amoxicillin, fluticasone nasal spray, and ofloxacin ear drops.

The entire encounter takes up 25 minutes of the provider’s face-to-face time with the patient.

Think you can code this note using both the 2020 and 2021 E/M guidelines? Turn to page 5 and compare your answers to those of our experts’.