Pediatrics and Family Practice
A woman brings her 3-year-old son, established patient, to
the physician's office for annual health supervision and
evaluation. During the preventive medicine encounter, the
physician notes inflammation of the right middle ear. Upon
further questioning, the mother recalls a two day history of the
child pulling at his right ear. He has been irritable, running a
low grade fever, coughing, and has had difficulty sleeping at
night. The physician then (additionally) performed the key
components of a problem-oriented evaluation and
management service.
Appropriate laboratory tests were ordered. Antibiotics were
prescribed and a follow-up visit was scheduled. The
physician diagnosed acute right otitis media, acute tonsillitis,
and acute adenoiditis.
To report this, CPT code 99392 would be used for the
preventive medicine services visit. In addition, the
appropriate problem oriented level of E/M service should
be selected based on the key components associated
with providing the problem oriented E/M service.