Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
SUBJECTIVE:
6-year-old girl, new patient, complains of fever and cough. Dad is in the room and providing the HPI. Symptoms started yesterday. The cough is nonproductive. Possible exposure to COVID-19 2 days ago at school. Associated symptoms include fatigue, body aches, nasal congestion, and loss of appetite. Pertinent negatives include no chest pain, headaches, or vomiting. Her fever is alleviated by OTC acetaminophen.
Review of Systems
- Constitutional: Positive for malaise/fatigue. Negative for chills.
- HEENT: Positive for congestion.
- Eyes: Negative
- Cardiovascular: Negative for chest pain.
- Respiratory: Positive for cough. Negative for shortness of breath.
- Skin: No rash
- Gastrointestinal: Negative for diarrhea and vomiting.
- Neurological: Negative for headaches.
Past Medical History
- None
Current Medications
- OTC acetaminophen
Drug Allergies
- None known
OBJECTIVE
BP 112/69 (BP Location: Right arm, Patient Position: Sitting) | Pulse 129 | Temp 102.2 °F (Tympanic) | Resp 28 | SpO2 94% | 52 pounds
Physical Exam
Constitutional:
General: She is not in acute respiratory distress.
Appearance: She is mildly ill-appearing.
HENT:
Nose: Mucosal edema present. No congestion.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: No posterior oropharyngeal erythema.
Cardiovascular:
Rate and Rhythm: Tachy rate and regular rhythm.
Heart sounds: Normal heart sounds.
Musculoskeletal:
Right lower leg: No edema.
Left lower leg: No edema.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Breath sounds: No stridor. Examination of the lung fields reveals rhonchi. Rhonchi (Diffuse mild rhonchi R>L. Coarse cough.) present. Rales right lung field. No wheezing.
Skin:
General: Skin is warm and dry.
Neurological:
General: No focal deficit present.
Mental Status: She is alert.
Psychiatric:
Behavior: Behavior normal.
Radiology interpretation
I personally viewed the two view CXR which shows an infiltrate in the right middle lobe. No mass or pneumothorax.
Lab orders placed this encounter:
POCT COVID test is negative
POCT Influenza test is negative for type A & B.
IMPRESSION/PLAN
- Right middle lobe pneumonia
- Exposure to COVID
See specific instructions and follow up as given to patient/caregiver below. We discussed the risk and benefits of taking Amoxil and Zithromax including side effects and allergic reactions.
Follow-up with your pediatrician this week. Go to the ED if symptoms worsen. Take OTC Tylenol PRN for fever and body aches. Increase fluids and plenty of rest.
New Prescriptions
- Amoxil (400 mg/5 mL) 2¾ teaspoons BID for 10 days
- Zithromax (200 mg/5 mL) 1 teaspoon PO day 1 and then ½ teaspoon PO days 2-5
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
The patient complains of fever, cough, fatigue, nausea, and body aches. This would meet the criteria for an “acute illness with systemic symptoms,” which is Level 4 (Moderate).
Amount and/or Complexity of Data to be Reviewed and Analyzed
Two point-of-care tests were ordered (COVID-19 and influenza), along with a chest x-ray. Do not count the chest x-ray as a point if your company bills for the professional component of the radiograph. If your company does not bill for the professional component of the x-ray, then it would count as 1 point. The 2 point-of-care tests and independent historian meet the criteria for Category 1 in the Complexity of Data, resulting in Level 4 (Moderate) in this category.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Prescription medications (Amoxil and Zithromax) were prescribed. This would meet the criteria for 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 in the Problems Addressed, Complexity of Data, 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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