Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
A 58-year-old man presents to the urgent care clinic as a new patient after sustaining a closed head injury during a fall from a ladder approximately 3 hours ago. He reports that he fell approximately 8 feet and landed on his right side, striking his head on the ground. He experienced immediate dizziness and confusion but did not lose consciousness. Since the injury, he has had persistent headaches, nausea, and 1 episode of vomiting. He denies any vision changes, seizures, or neck pain. His medical history is unremarkable, and he has no known allergies. His spouse was in the room and providing part of the history of present illness due to the patient’s confusion.
OBJECTIVE
- Blood pressure: 140/85 mm Hg
- Heart rate: 95 beats/min
- Respiratory rate: 18 breaths/min
- SPO2: 98%
- Temperature: 98.7°F (37.1°C)
- General: Alert and oriented x 3, appears uncomfortable due to headache.
- HEENT:
- Head: No visible lacerations or hematoma but there is a superficial abrasion to the right temporal area. TTP to the right temporal area.
- Eyes: PERRLA, EOMI
- Ears: TMs intact, no drainage or blood noted
- Neck: No tenderness to palpation, full range of motion
- Chest: No TTP, bruising or wounds noted. CTAB, no rhonchi, rales, or wheezing.
- Heart: RRR without murmur
- Neurological exam:
- Cranial nerves: CN II-XII grossly intact
- Motor function: Strength 5/5 in all extremities, no focal neurological deficits.
- Sensory: Intact to light touch and pinprick.
- Coordination: Normal finger-to-nose.
- Gait: Unsteady, mild ataxia observed.
- Extremities: No gross deformities noted, TTP to the right elbow and shoulder.
ASSESSMENT
- Closed head injury
- Unsteady gait
- Right shoulder pain
- Right elbow pain
PLAN
EMS was called due to the patient having initial confusion, dizziness, persistent headache, and emesis. I am concerned for an intracranial hemorrhage. He is alert and oriented x 3, but he has an unsteady gait.
EMS arrived within 5 minutes and the patient was transported to the ED for further evaluation and management.
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
- The patient’s chief complaint is a head injury and right elbow/shoulder pain after a fall off a ladder.
- The patient looks ill and has an unsteady gait.
- This is an acute illness/injury that poses a threat to life or bodily function.
E/M Level for this category: Low, Level 3
Amount and/or Complexity of Data to be Reviewed and Analyzed
- The decision was made to call EMS for transportation to the emergency department.
- No labs were performed.
- The provider did not discuss management with an external clinician or review external notes.
- An independent historian was used and documented.
E/M Level for this category: High, Level 5
Risk of Complications and/or Morbidity or Mortality of Patient Management
- The patient was transferred to the emergency department by EMS.
- The patient may have a life-threatening head injury.
E/M Level for this category: High, Level 5
2 of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 5 criteria were met in the Problems Addressed and Risk categories, so the correct E/M code is 99205.
| 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
EB Medicine’s Upskill Academy is a customized curriculum for urgent care groups. For more information, contact Dana Stenzel, Account Executive, at 678-336-8466 x120 or Danas@ebmedicine.net
