Final answer:
The correct answer is 99213, which is the code for an established patient office visit with a problem-focused history and exam, as well as low complexity medical decision making. This code is used for conditions like acute otitis media, a common ear infection presenting with symptoms like ear pain and inflammation.
Step-by-step explanation:
The correct code for the scenario where an established patient is seen for an earache, with a history and exam that are problem-focused and medical decision making (MDM) is low, is 99213. The diagnosis made is otitis media, right side. The CPT code 99213 is appropriate for an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and medical decision making of low complexity.
Acute otitis media (AOM) is a common infection characterized by pus accumulation in the middle ear, leading to inflammation and often symptoms such as ear pain (otalgia), fever, and in some cases nausea, vomiting, and diarrhea. Chronic cases may involve fluid accumulation known as otitis media with effusion (OME), increasing the risk of recurrent infections and chronic earaches, particularly in young children.