Coding Challenge: Epistaxis in Urgent Care

Determine the correct evaluation and management (E/M) service code for this urgent care encounter:

A 67-year-old established male patient presents to urgent care with a chief complaint of a nosebleed.
The nosebleed started approximately 6 hours ago while he was sitting at home watching television. He attempted to stop the bleeding by applying pressure, but this was unsuccessful. He reports a history of previous nosebleeds, which are usually controlled with direct pressure. He denies any recent trauma or known injuries. Additionally, he reports no chest pain, dyspnea, dizziness, fatigue, recent upper respiratory infection, or headache. His medical history includes hypertension and pulmonary embolism.

Past Medical History

  • Hypertension (2002)
  • Pulmonary embolism (2009, 2017)

Current Medications

  • Amlodipine, 5 mg once daily
  • Warfarin, 5 mg once daily

Drug Allergies

  • Penicillin, which causes a rash

OBJECTIVE

  • BP: 131/83 mm Hg
  • HR: 109 beats/min, regular
  • RR: 16 breaths/min
  • Temp: 98.9°F
  • SpO2: 96%
  • Height: 6’ 0”
  • Weight: 181 lbs
  • General appearance: Alert and oriented × 3, sitting on exam table, no acute respiratory distress, holding a bloody towel to his nose.
  • HEENT:
    • PERRLA, no scleral icterus, conjunctiva without erythema
    • Oropharynx clear, no erythema or exudates, and no blood in the posterior oropharynx
    • TMs clear without erythema
    • Neck: Nontender cervical adenopathy bilaterally, no JVD or masses
  • Lungs: CTAB, no rales, rhonchi, or wheezing
  • Heart: Tachycardic rate without murmur
  • Skin: Warm and dry, good skin turgor; no rash or petechiae on the extremities

Clinic Orders:

  • Point-of-care CBC is within normal limits
  • Urgent referral to ENT
  • Initial treatment involved holding pressure to the nose for 10 minutes, which was unsuccessful.
    A cotton ball saturated with oxymetazoline was then applied, and after 30 minutes, the
    bleeding stopped.
  • I consulted his primary care provider, Dr. Williams, who will see him tomorrow for PT/INR
    blood work. I also spoke with Dr. Anderson (ENT), who agrees with the current treatment
    and will see the patient in her office tomorrow morning.

ASSESSMENT

  • Epistaxis
  • History of pulmonary embolism
  • Long-term anticoagulant use

PLAN

We discussed the CBC results. I reinforced instructions on what to do if his symptoms return. If the
bleeding recurs and he is unable to control it, he is to go to the emergency department for further
evaluation. He was instructed to call with any questions or concerns. He will follow up tomorrow
with both the ENT specialist and his primary care provider. He is to continue his warfarin as directed
and will have blood work for PT/INR tomorrow.

CHALLENGE: What is the appropriate E/M code for this encounter?

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