Wiki Urgent Care referred to the ED

[ACollison]

Hello -

I need some advice on if this can even be coded. We had a patient present at our Urgent Care that was referred to go to the ED. Is there enough information
below to support a 99211?


Visit Type: Urgent Care Visit
Document Type: Chart Note
___________________________________________________________________________________________

ESTABLISHED PATIENT VISIT

History of Present Illness
This 16 year 8 month old male presents with:
1. headache
2. sore throat

Allergies
No known allergies.
Reviewed, no changes.

Past Medical/Surgical History Reviewed, no changes.
Last document/updated: 01/28/2018.

Condition Procedure/Surgery

Asthma


Family History Reviewed, no changes.
Last document/updated: 01/28/2018.


Social History Review, no changes.
Last document/updated: 01/28/2018.

ALCOHOL:
There is no history of alcohol use.



Physical Exam

Comments: Pt was having lot of chest pain and dizziness and he was passing out. I advised pt to go to the ER for some quick labs and possible head CT with the neurological symptoms. Mother is taking the pt to the ER

Assessment Plan
Dizziness (R42)
Syncope, unspecified syncope type (R55)