High School

Assign the appropriate CPT E/M level, procedures, and ICD-10-CM code(s) for the following physician office encounter:

- **Patient Information**: 13-year-old new patient
- **Chief Complaint**: Abdominal pain after dinner
- **History**: Ate spaghetti approximately 4-5 hours ago; nausea and vomiting accompanied by abdominal pain
- **Examinations**:
- Ears, nose, throat, abdomen, and chest were examined and found to be normal
- Abdominal x-ray and CBC results were normal
- **Treatment**: Prescribed Compazine
- **Diagnosis**: Food poisoning

**Instructions**:
1. Sequence the E/M level first when there are multiple CPT codes.
2. Sequence the first-listed diagnosis first when there are multiple ICD-10-CM codes.

Answer :

When assigning CPT and ICD-10-CM codes for a 13-year-old patient with food poisoning, the appropriate E & M level code such as 99203 or 99204 will be used along with ICD-10-CM codes from the T62-T65 range, reflecting the diagnosis and treatment provided.

When a 13-year-old patient presents with abdominal pain, nausea, and vomiting, and is diagnosed with food poisoning after a physician's office encounter, a medical coder will need to assign the appropriate CPT E & M level for the office visit, any relevant procedures, and ICD-10-CM code(s) for the diagnosis. Since the patient is a new patient, the E & M level will reflect a comprehensive history and examination .