The physician sees a 4-month-old in the office on Monday morning. This is the infant's third episode of acute, purulent otitis media with fever and cough within the last 3 months. A detailed history and physical examination are performed and documented. Medical decision-making is moderately complex.
Later on the same day the infant is brought back to the office because her mother wants her checked for any possible injuries following a minor car accident. The same physician performs a brief history and detailed physical examination. The examination is normal and medical decision-making is straightforward.
How will you report these services?
Current Procedural Terminology (CPT®) guidelines specify that one evaluation and management (E/M) service can be reported for services provided to a patient by the same physician (or another physician of the exact same specialty or subspecialty in the same group practice with the same tax identification number) on...