In the clinic office a pediatrician sees a 12-year-old old girl for headache, dizziness, and neck pain. The previous night, she had been struck in the face with a ball while playing a game of dodge ball

Question

Patient felt progressively worse as the night progressed. ROS pertinent to chief complaint: no nausea or vomiting, fever, or shortness of breath. All other ROS unremarkable. The patient's social history has not changed since her most recent annual physical. Physical exam: pupils equal, round, and reactive to light. Ocular nerves intact. Patient expresses significant pain upon palpation of shoulders and along cervical spine, but no dizziness upon palpation. Patient can stand on one foot with appropriate balance and displays good range of motion. Neck soft without lumps or tenderness. Cervical lymph nodes are normal. Plan: patient shows no sign of infection, cranial injury, or concussion. The physician discussed mother's concern regarding head injury, instructed mother and patient regarding signs and symptoms of concern, and recommended ibuprofen or Tylenol for neck pain. Which of the following E/M codes best reflects the documented service? a. 99203
b. 99213
c. 99221
d. 99219

Answer 1

b) 99213