Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
SUBJECTIVE:
64-year-old male, new patient, presents to your urgent care with a chief complaint of acute onset of left knee pain. He states that he has “arthritis” of his left knee, which is being treated by his orthopedic physician. He does state this is a chronic, intermittent problem. No history of knee replacement or any steroid injections. His symptoms started late last night and have progressively worsened this morning. No fever, rash, or other complaints. He denies any trauma but has been working more in the yard recently. He has taken OTC Tylenol® and ibuprofen, which have helped decrease the pain from a 7 to a 5.
Current Medications
- OTC ibuprofen and Tylenol®
- Hydrochlorothiazide 25 mg once daily for HTN
Drug Allergies
- Bactrim – Rash
OBJECTIVE
- Time: 10:30 am
- Temp 98.5°F
- BP 137/90 mm Hg
- Pulse 84 Reg
- Resp 18
- SpO2 97%
- Ht 5′ 11″
- Wt 220 lbs
- General appearance: Sitting in a wheelchair, alert, cooperative, appears in pain
- HEENT: Normocephalic
- Lungs: Clear to auscultation bilaterally
- Heart: Normal, regular rhythm, S1, S2 normal, no murmur, click, rub, or gallop
- Left knee: There is generalized TTP, mostly to the medial joint line. No erythema or warmth. Limited ROM due to pain. There is a small effusion noted. No rash or wounds.
- Skin: No rash
ASSESSMENT
- Acute left knee pain
- OA left knee
- 3-view radiographs of the left knee reveal moderate DJD with osteophyte formation. Mild effusion noted. No acute fracture.
PLAN
- Meloxicam 7.5 mg once daily PRN pain.
- Simple ROM exercises as tolerated.
- Rest, elevation, and ice PRN.
- If symptoms persist or worsen, he will follow up here or with his orthopedic surgeon.
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 left knee pain. He states this is a chronic, intermittent problem. This would meet the criteria for “1 chronic illness with exacerbation, progression, or side effects of treatment,” which is Level 4 (Moderate).
Amount and/or Complexity of Data to be Reviewed and Analyzed
No lab tests were ordered, no external notes were reviewed, and no documentation was provided by an independent historian, the clinician did order a x-ray of the left knee. The healthcare system does bill for the professional component of x-rays so this would not count towards the complexity of data. This section would be Level 2 (Straightforward).
Risk of Complications and/or Morbidity or Mortality of Patient Management
The clinician prescribed meloxicam, which would meet the criteria for prescription drug management. This is Level 4 (Moderate) risk.
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
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Last Updated on December 5, 2023
