Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
A 22-year-old man, established patient, presents to your urgent care with a chief complaint of right-hand discomfort after “shocking” his hand while plugging in a blender. The symptoms started about 3 hours ago. He has taken OTC ibuprofen with moderate relief of the pain. No CP, SOB, palpitations, rash, dizziness, abdominal pain, right arm paresthesia or vomiting.
PAST MEDICAL HISTORY
- None
CURRENT MEDICATIONS
- None
DRUG ALLERGIES
- No known drug allergies
OBJECTIVE
- BP 121/84 mm Hg
- HR 106 Reg beats/min
- RR 20 breaths/min
- Temp 98.9
- SPO2 98%
- Ht. 5’7”
- Wt. 178 lbs.
- A&OX3, sitting on exam table, no acute respiratory distress
- HEENT: PERRLA, no scleral icterus, conjunctiva without erythema. Fundoscopic exam is negative. Oropharynx: Clear, no erythema or exudates. TMs clear without erythema, TMs intact.
- Neck: No adenopathy or JVD
- Lungs: CTAB, no rales, rhonchi, or wheezing
- Heart: Tachycardic rate without murmur
- Abdomen: BSX4, no rebound or guarding
- Neuro: CN II-XII grossly intact
- Extremities: right arm- no wounds, burns, discoloration, or ecchymosis. FAROM without pain. Skin: warm and dry. No rash on the extremities. Capillary refill is 2 seconds.
CLINIC ORDERS
- ECG shows sinus tachycardia. No Q waves, ST-T abnormalities, or other abnormalities. No comparison.
ASSESSMENT
- Right arm pain
- Electrical injury
PLAN
Stable patient who sustained a low-voltage electrical shock. We monitored his ECG for 60 minutes. I discussed with the patient the symptoms to watch out form, such as chest pain, dyspnea, visual complaints, abdominal pain, and extremity paresthesia. If any of these symptoms arise, he should call 911 and be evaluated in the ED. He will take OTC acetaminophen as needed for pain. He agrees with the plan. He can call our office anytime for any questions or concerns. He will follow up with his primary care provider in the next 3 days.
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
An established patient complains of right arm discomfort following an electrical shock. Vital signs are stable, no comorbid conditions, and he is in no acute distress. This would be a low, level 3 problems addressed.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician ordered an ECG. If your healthcare system bills for the professional interpretation of the ECG, you cannot count it as a point. The clinician did not discuss the case with an external source or discuss the interpretation of the ECG with an external source. This would meet the criteria for a straightforward, level 2 complexity of data.
Risk of Complications and/or Morbidity or Mortality of Patient Management
This patient was discharged in stable condition. No prescription medications were prescribed. There is documentation of OTC medications, which would be a low, level 3 risk of patient management.
Two of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 3 criteria were met in the Problems Addressed and Risk categories, so the correct E/M code is 99213.
| 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 April 24, 2024
