Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION
56-year-old male new patient with C/C of right-shoulder injury, which occurred about 2 hours ago. He states he slipped on ice while getting his mail this morning. He is right handed. He is complaining of moderate-severe pain in the right shoulder. He has taken acetaminophen, which has not helped. He denies numbness, tingling, or pain radiating down the right arm. He is unable to move the right arm due to pain. No history of right shoulder problems.
Past Medical History
Hypertension
Current Medications
- OTC acetaminophen
- Hydrochlorothiazide 25 mg once daily
Drug Allergies
Penicillin, which causes hives
OBJECTIVE
- BP: 136/82 mm Hg
- HR: 77 beats/min Reg
- RR: 14 breaths/min
- Temp: 98.7°F
- SPO2: 99%
- General: A&O×3, he is holding his right arm flexed at the elbow and close to his abdomen. He is using a pillowcase as a sling.
- HEENT: normocephalic, atraumatic, PERRLA
- Resp: CTAB
- Heart: RRR without murmur
- Right upper extremity: There is severe TTP to the right proximal humerus and with STS but no gross deformity. No wounds or ecchymosis. Very limited ROM due to pain. Good sensation and capillary refill distally.
- 3-view radiographs were taken of the right shoulder. I personally viewed the radiographs and found a mildly displaced (2-part) proximal humerus surgical neck fracture.
- I contacted and discussed the management with Dr. Jones (external provider). She agrees with the high risk of complications and will see him at her office in 30 minutes.
- A sling and swathe were applied to the right upper extremity. He will be driven to the orthopedist’s office by his wife.
CLINIC ORDERS
3-view radiographs of the right shoulder
ASSESSMENT
Right proximal humerus fracture
PLAN
After discussion with Dr. Jones, his wife will take him to the orthopedics office now. Referral has been placed.
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What is the appropriate E/M code for this encounter?
Consider this patient encounter using the elements of medical decision making to select the appropriate level of service:
Number and Complexity of Problems Addressed
The patient’s chief complaint is right shoulder pain. The criteria are met for an acute, complicated injury due to severe pain, lack of mobility, and a displaced fracture. This is Moderate, Level 4, in the Problems Addressed category.
Amount and/or Complexity of Data to be Reviewed and Analyzed
An x-ray of the right shoulder was performed in the clinic; however, this is not a point in this category because it is a separately reported service. The clinician did call an external provider, Dr. Jones, to discuss the management of this patient. This is Moderate, Level 4, in the Data category.
Risk of Complications and/or Morbidity or Mortality of Patient Management
The patient has a moderate-high risk of complications/morbidity from this injury. An urgent referral was placed to an orthopedic specialist. This meets the criteria for Moderate, Level 4, in the Risk/Patient Management category.
Two of the 3 elements of medical decision making must be met or exceeded when choosing the overall level of service. Level 4 criteria were met in all 3 categories, so the correct E/M code is 99204.
