DecisionHealth, DecisionHealth - 2023 Issue 5 (May)

Report the right E/M level for ED patient with exacerbated chronic illness

Question: A 19-year-old male with asthma who experienced wheezing and shortness of breath for the past two weeks presented to the emergency department (ED). Inhaler use 10-14 times daily offered temporary relief. Physical exams were normal except for tachycardia, scattered wheezing breath sounds, and elevated respiration. The physician completed three tests (complete blood count; complete metabolic panel; influenza A/B, respiratory syncytial virus, and COVID-19 polymerase chain reaction panel), gave the patient a nebulizer treatment and steroids, released him with MDI and steroid burst, and referred him for a follow-up visit with his doctor of primary medicine. Which CPT code would be reported for this visit?

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