What is the billing code for a 10-minute office visit for a patient presenting with cough, fever, and shortness of breath, with a review of their medication (meds), medical history, and allergies?

Billing Code for 10-Minute Office Visit with Cough, Fever, and Shortness of Breath

For a 10-minute office visit evaluating a patient with cough, fever, and shortness of breath, including review of medications, medical history, and allergies, the appropriate billing code is CPT 99213 (established patient) or 99203 (new patient), representing a low to moderate complexity evaluation and management service.

Clinical Context and Coding Rationale

The presenting symptoms of cough, fever, and shortness of breath constitute a potentially serious respiratory illness requiring medical decision-making to differentiate between conditions such as:

• Pneumonia - suggested by fever ≥38°C, tachypnea, dyspnea, and new chest examination findings 1
• Acute bronchitis - typically viral with cough lasting 2-3 weeks without pneumonia findings 2
• COVID-19 or other viral respiratory infections - presenting with cough, fever, shortness of breath, and myalgias 1, 3, 4
• Asthma exacerbation - with cough, wheeze, and shortness of breath 1

Key Documentation Elements for Coding

History Components (Documented in 10-Minute Visit)

• Chief complaint: Cough, fever, shortness of breath 1
• Medication review: Completed as stated
• Medical history review: Completed as stated
• Allergy review: Completed as stated

Physical Examination Priorities

The examination should document:

• Vital signs: Temperature (fever ≥38°C suggests pneumonia), respiratory rate (>30 breaths/min indicates severity), oxygen saturation (<93% suggests pneumonia) 1
• Lung examination: Presence/absence of crackles, diminished breath sounds, tachypnea, or localizing chest signs 1
• General appearance: Respiratory distress, ability to speak in full sentences 1

Medical Decision-Making Complexity

Moderate complexity is justified when the differential includes:

• Pneumonia requiring potential chest radiography and antibiotic consideration 1
• Viral respiratory infection requiring symptomatic management 1, 2
• Potential need for influenza antiviral therapy within 48 hours of symptom onset 1

CPT Code Selection

For Established Patients:

• 99213: Office visit, 20-29 minutes OR low to moderate complexity medical decision-making
  • Appropriate when evaluating respiratory symptoms requiring differentiation between viral illness and pneumonia
  • Includes medication/allergy/history review as documented

For New Patients:

• 99203: Office visit, 30-44 minutes OR low to moderate complexity medical decision-making
  • Same clinical scenario but for patients not seen within past 3 years

Common Pitfalls to Avoid

• Undercoding: A 10-minute visit with these symptoms and required reviews typically meets 99213/99203 criteria based on medical decision-making complexity, not just time 1
• Missing documentation: Ensure vital signs (especially temperature, respiratory rate, oxygen saturation) are documented to support pneumonia evaluation 1
• Inappropriate antibiotic prescribing: If no pneumonia evidence exists (normal vital signs, normal lung exam), antibiotics are not indicated and this should be documented 1, 2

Additional Considerations

If chest radiography is ordered during the visit due to abnormal vital signs or concerning examination findings, this supports the moderate complexity level 1. The absence of runny nose with presence of breathlessness, fever ≥38°C, and abnormal lung findings increases pneumonia likelihood and justifies diagnostic workup 1.

For patients with suspected influenza, initiating antiviral treatment within 48 hours may decrease antibiotic use and hospitalization, which should be documented if applicable 1.