Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION
10-year-old female new patient complains of left ear pain. Mom is in the room and providing the history of present illness. The symptoms began 4 days ago. Pain is of moderate severity. Fever is absent. No ear drainage or headache. Other associated symptoms have included sinus congestion. Fluid intake is good. Current medications include ibuprofen, which helps with the pain.
Current Medications
OTC ibuprofen
Drug Allergies
No known drug allergies
OBJECTIVE
- BP: 117/77 mm Hg
- HR: 98 beats/min Reg
- RR: 18 breaths/min
- Temp: 99.5°F
- SpO2: 99%
- Weight: 98 lbs
- General appearance: Alert, cooperative, and in no distress
- Head: Normocephalic
- Eyes: PERRLA, no injection or drainage.
- Ears: There is moderate bulging and erythema to the left tympanic membrane. No drainage.
The right tympanic membrane is dull but no erythema. - Nose: Turbinates inflamed but no erythema
- Throat: Postnasal drainage but no erythema
- Neck: Supple, no adenopathy
- Lungs: Clear to auscultation bilaterally
- Heart: Normal, regular rhythm; S1, S2 normal; no murmur, click, rub, or gallop
- Skin: Skin color, texture, turgor normal. No rashes or lesions.
CLINIC ORDERS
None
ASSESSMENT
- Left otitis media
- URI
PLAN
- Discussed diagnosis with mom and patient. Stressed fluid hygiene hydration. Push comfort measures to include OTC ibuprofen as needed for pain. Follow up here in 3 to 4 days if not improved or sooner if symptoms worsen.
- Medication changes and new medications: Amoxicillin 875 mg BID for 10 days
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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 complaints are left ear pain and sinus congestion. This would be 1 acute, uncomplicated illness or injury, which is Low, Level 3.
Amount and/or Complexity of Data to be Reviewed and Analyzed
In this case, the clinician did not order any tests but did document an independent historian, which meets the criteria for Low, Level 3.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Amoxicillin was prescribed. This meets the criteria of prescription drug management for Moderate, Level 4.
What is the appropriate E/M code for this encounter?
Two of the 3 elements of medical decision making must be met or exceeded when choosing the overall level of service. Level 3 criteria were met in 2 categories (Problems Addressed and Complexity of Data), while Level 4 criteria was met only in the Risk of Patient Management category, so the correct E/M code is 99203.
