Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION:
44-year-old female new patient complains of “asthma attack” after 4 days of increasing wheezing. She has been using her albuterol inhaler which has not helped as much today. She will have exacerbation of her asthma when her seasonal allergies “flare up.” No fever, CP, headache, N/V/D, abdominal pain, or rash. She does have a history of asthma. No history of tobacco use.
Past Medical History
- Asthma
- Allergic rhinitis
Current Medications
- Albuterol MDI 2 puffs Q4hrs PRN
- OTC Allegra® 60 mg daily PRN
Drug Allergies
- PCN
EXAMINATION
- BP 138/88 mm Hg
- HR 108 beats/min
- RR 20 breaths/min
- Temp 98.8°F
- SPO2 95%
- A&O x 3, no acute respiratory distress, speaks in complete sentences
- HEENT: PERRLA, TMs intact, PND noted, oropharynx – no erythema or exudates
- Neck: supple, no adenopathy
- Lungs: bilateral expiratory wheezing
- Heart: Tachy rate but no murmur
ASSESSMENT
- Asthma exacerbation – J45.901 Primary
Medications Prescribed During the Encounter
- Prednisone taper (60 mg x 3, 40 mg x 3, 20 mg x #) over 9 days
- Solu-Medrol® 40 mg IM injection in clinic
PLAN
- Prednisone taper (60 mg x 3, 40 mg x 3, 20 mg x #) over 9 days
- Solu-Medrol® 40 mg IM injection in clinic
- Continue albuterol MDI PRN
CHALLENGE: What is the appropriate E/M code for this encounter?
Let’s consider this patient encounter using a simplified Elements of Medical Decision Making table to find the appropriate LOS.1
Number and Complexity of Problems Addressed
Patient complains of asthma exacerbation. This is a chronic illness with exacerbation, which would be Level 4 (Moderate).
Amount and/or Complexity of Data to be Reviewed and Analyzed
There were no labs ordered or other data reviewed. Complexity of data would be Level 2 (Minimal).
Risk of Complications and/or Morbidity or Mortality of Patient Management
The provider ordered a Solu-Medrol® injection and prescribed a prednisone taper. Risk would be Level 4 (Moderate) due to prescription drug management.
Two of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 4 criteria were met or exceeded in the Problems Addressed and Risk categories, so the correct E/M code is 99204.
| MDM Levela | Problems Addressed | Complexity of Data | Risk of Complications | E/M Service Codes |
| Level 2: Straightforward | Minor/self-limited | Minimal/none | Minimal risk | 99202 99212 |
| Level 3: Low | One of these: • ≥2 self-limited/minor problems • 1 stable chronic illness • 1 acute uncomplicated illness or injury • 1 stable acute illness • 1 acute uncomplicated illness or injury requiring hospital care | Meets at least 1 of these categories: Category 1: Any 2 of these: • Review of external notes from unique source • Review of test results from unique source • Order of unique test Category 2: • Assessment of independent historian | Low risk • Example: OTC medication management | 99203 99213 |
| Level 4: Moderate | One of these: • ≥1 chronic illness with exacerbation • ≥2 stable chronic illnesses • 1 undiagnosed new problem (uncertain prognosis) • 1 acute illness with systemic symptoms • 1 acute complicated injury | Meets at least 1 of these categories: Category 1: Any 3 of these: • Review of external notes from unique source • Review of test results from unique source • Order of unique test • Assessment of independent historian Category 2: Interpretation of test performed by external source Category 3: Discussion of test or management with external clinician | Moderate risk • Examples: Prescription drug management; significant social determinants of health | 99204 99214 |
| Level 5: High | • ≥1 chronic illness with severe exacerbation or progression | Meets at least 2 of these categories: Category 1: Any 3 of these: • Review of external notes from unique source • Review of test results from unique source • Order of unique test • Assessment of independent historian Category 2: Interpretation of test performed by external source Category 3: Discussion of test or management with external clinician | High risk • Example: Decision to escalate to hospital care | 99205 99215 |
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.
1American Medical Association. Evaluation and Management (E/M) Services Guidelines. Accessed January 1, 2023. Accessed October 10, 2023. Available at: http://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
For an in-depth review of this topic, access the full course.
