A 3-year-old patient is seen in the office and evaluated for diarrhea. He has had watery stools for a few days. He is playful and active, is voiding well, and does not have a fever. He is not on any medications. He attends child care. An examination of constitutional, ears, throat, heart, lungs, abdomen, and skin is performed and all results are documented as negative. The diagnosis is acute gastroenteritis. The mother is advised to push fluids, monitor for fever or dehydration, and return to the office if his condition continues or worsens.

Based on the performed and documented medical decision-making (MDM) (Table 1), history (Table 2), and physical examination (Table 3), the service would be reported with Current Procedural Terminology (CPT®) code 99213 (for an established patient) or 99202 (for a new patient) (Table 4).

The same 3-year-old patient returns 3 days later with chief complaint of diarrhea. He...

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