Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION
26-year-old female new patient presents with a chief complaint of lower abdominal pain, nausea,
and vaginal bleeding for 2 weeks. She is concerned about the increasing blood loss. It started as
intermittent spotting but has become heavier, with clots, over the past 3 days and she started having
lower left abdominal/pelvic pain. She is using multiple pads per day. She has a history of irregular
menstrual cycles. She is sexually active with her spouse. G1 P1. She denies chest pain, shortness of
breath, headache, fever, dysuria, or dizziness.
Past Medical History
Asthma
Current Medications
Birth control pills
Albuterol inhaler
Drug Allergies
No known drug allergies
OBJECTIVE
- BP: 102/72 mm Hg
- HR: 109 beats/min Reg
- RR: 17 breaths/min
- Temp: 99.2°F
- SpO2: 96%
- General appearance: A&O×3, looks ill and appears anxious
- HEENT: normocephalic, atraumatic, PERRLA
- Abdomen: soft, tender to palpation to the left lower quadrant, BS×4, no guarding, rebound,
or rigidity - Pelvic examination:
- External genitalia: Normal appearance, no
lesions or discharge noted.
- External genitalia: Normal appearance, no
- Speculum examination:
- Cervix: visualized, bright red blood from the os
- Vaginal walls: no erythema
- Blood: bright red blood present in the vaginal canal, with clots noted
- Bimanual examination:
- Uterus: mild enlargement noted, normal position, slight TTP, anteverted
- Adnexa: tenderness on the left side
- Resp: CTAB
- Heart: tachycardic rate without murmur
LAB ORDERS
- Urine pregnancy test is negative
- CBC is within normal limits except Hgb 9.3
I contacted and discussed the management with Dr. “OB/GYN” (external provider). She agrees to
see the patient at her office in 60 minutes. The patient was informed and will be driven to the
clinician’s office.
ASSESSMENT
- Abnormal uterine bleeding
- Pelvic pain
PLAN
Due to her presenting symptoms, tachycardia, ill-appearance, and pelvic pain, after discussion with Dr. “OB/GYN”, she will be evaluated by her gynecologist for further evaluation/management. She will be driven to the gynecologist’s office by her spouse.
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 complaints are abnormal vaginal bleeding, nausea, and left lower abdominal/
pelvic pain. She looks ill and is tachycardic. The specific diagnosis is uncertain. This would meet
the criteria for an acute illness with systemic symptoms (vaginal bleeding, abdominal/pelvic pain,
and nausea) and an undiagnosed new problem with uncertain prognosis, both of which meet the
criteria for Moderate, Level 4.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician called an external provider (Dr. “OB/GYN”) to discuss the management of this patient. A point-of-care urine pregnancy test and a CBC were also obtained during the office visit. The discussion with the external clinician meets the criteria for Moderate, Level 4.
Risk of Complications and/or Morbidity or Mortality of Patient Management
The patient has a moderate-high risk of complications/morbidity from this illness, and an urgent
referral was placed to a gynecologist. This meets the criteria for Moderate, Level 4 risk.
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.
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