The pediatrician diagnosed oral allergy syndrome in seasonal allergic rhinitis. Oral allergy syndrome is assigned International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code T78.1, other adverse food reactions, not elsewhere classified, as directed by the alphabetic index. Seasonal allergic rhinitis is reported with code J30.2, other seasonal allergic rhinitis. Although the physician discussed the relationship between birch pollen allergy and food hypersensitivity, a diagnosis of allergic rhinitis due to pollen was not stated. If, after testing, a diagnosis of allergy due to pollen is documented, code J30.1 (allergic rhinitis due to pollen) would be assigned to future encounters rather than J30.2.

The evaluation and management (E/M) service was provided to an established patient, as the record indicated the patient was last seen 6 months ago. The physician documented face-to-face time of 15 minutes, with more than 50% of that time spent in counseling....

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