Reference no: EM133153104

Dr R sees a 20-year-old established patient for an office visit. The patient presents with complaints consistent with an upper respiratory tract infection (URTI). The physician reviews the medical history form completed by the patient and vital signs obtained by a medical assistant. A history (including response to treatment at last visit and review of old medical records) and a relevant examination are performed. Dr R confirms the straightforward URTI diagnosis. The patient asks for a prescription for antibiotics, and Dr R spends considerable time explaining current guidelines for management of uncomplicated URTIs and the serious consequences of antibiotic overuse. A progress note is then completed by the physician. Dr R spent 21 minutes performing patient activities. Using time, which E/M code(s) should be reported for this case study?