Question

A 3-year-old established patient with complaints of stomachache after dinner at home. Patient had pasta 3-4 hours ago and began experiencing nausea and vomiting. No respiratory symptoms. No past history of abdominal problems. Patient has history of bilateral ear tube placement. Exams of ENT, abdomen, and chest, and constitutional are performed. Abdomen series negative, labs negative. Patient prescribed Compazine for N/V, with diagnosis of food poisoning.

A. 99201
B. 99203
C. 99202
D. 99213

Answer 1

The correct E/M service code for an established 3-year-old patient with symptoms consistent with food poisoning and a straightforward case is 99213.

Step-by-step explanation:

The question concerns determining the appropriate Evaluation and Management (E/M) service code for a 3-year-old patient with symptoms of gastroenteritis, most likely due to food poisoning. Since the patient is an established one, has multiple systems reviewed (ENT, abdomen, chest, and constitutional), and has a straightforward case with no systemic diseases or complex decision making, the correct E/M service code is 99213. No hospitalization was required, making other codes like 99201, 99202, and 99203 incorrect, as these are more appropriate for new patients or for established patients with services that differ in complexity and detail from this case.