tci E/M Coding Alert - 2015 Issue 12

Reader Question: Focus on the Final Diagnosis

Question: A 14-year-old established patient presented with severe throat pain that she had been experiencing for three days. In addition, she also had a runny nose, pressure both above and below her eyes, and intermittent headaches. She first noticed the sinus pressure while running with the track team a week before, and it grew worse until she had to use warm compresses on her face and forehead. No one else in the family is sick and she has no other relevant history.Our pediatrician examined the patient and diagnosed her with acute tonsillitis and an acute frontal sinus infection...

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