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A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days.A detailed history is then taken.She had associated fever of 101 F yesterday.Mom treated her with Tylenol.The fever this AM is 99
f.She has had some chills and cough as well as some difficulty breathing.No nausea or vomiting.No prior history of otitis.Brother was sick earlier this week.The physician performed a detailed exam of the ENT as well as a limited exam of GI, lungs, and heart.Vital signs were taken in the office.The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic.The MDM is stated to be moderate.
CPT Code: ____________________
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