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22 September, 11:07

Daisy, a 10-year-old girl, was very sick when she presented for an office visit at her pediatrician's office. she was running a high fever, was very lethargic, had swollen glands, and showed signs of dehydration because of the vomiting she had been doing the previous night. the doctor decided, after a comprehensive history and physical, that daisy needed to be admitted to the hospital for lab workup, rehydration, antibiotics, and monitoring. daisy's pediatrician stopped in to the hospital that evening to evaluate her condition and check on lab results. medical decision making was high complexity.

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  1. 22 September, 11:21
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    In this case, the symptoms and sign are not enough to find the diagnosis so I guess the question is about CPT coding, not ICD-10. In CPT coding, admission of a patient into hospital ranged from 99221-99223 with different severity. Considering the patient is high complexity you probably want to put 99223 code for highest initial care.
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