An allergic reaction to the antibiotic

Case 1. Please code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable:

Location: Family medical center

Encounter Date: 9/7/xx

Provider: Snow Valley, MD

Patient: Heather Williams

Gender: F

Age: 43-year-old established patient

Chief Complaint: Rash, diabetes, HTN and shortness of breath after taking amoxicillin. Patient was placed in observation after an allergic reaction to the antibiotic. The amoxicillin was discontinued. Has severe dermatitis covering arms, stomach and legs. Patient was admitted to observation for further treatment and supervision. Later in the day the dermattis began fading and breathing became normal. Patient was discharged on the same date. Physician performed a detailed exam and a detailed history, and medical decision making was moderate.

Diagnosis: Localized dermatitis and shortness of breath due to amoxicillin.

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