Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
Presentation
23 y/o male patient with C/C of right-hand injury and wound. He is a new patient. He states he was in a fight 6 days ago and punched another male. He states he has a wound to the right hand, which is now very painful and red. He has also noted greenish drainage. He is right-handed. Prior treatment includes bacitracin and ice; he has taken Ibuprofen for the pain, but says it does not help.
Past Medical History
None
Current Medications
OTC Ibuprofen
OTC Bacitracin
Drug Allergies
NKDA
OBJECTIVE
BP 116/82
HR 88Reg
RR 14
SPO2 99%
Temp 98.2°F
General: A&OX3, NAD, does not appear ill
HEENT: normocephalic, atraumatic, PERRLA
Resp: CTAB
Heart: RRR without murmur
Extremities: Right hand has a 2 cm laceration overlying the third MCP joint with surrounding erythema 4 cm X 5 cm. No obvious drainage currently. Very limited ROM due to pain. Good sensation and capillary refill distally.
3-view radiographs were taken of the right hand. I personally viewed the radiographs and found no acute fracture or dislocation.
I contacted and discussed the management with Dr. “Ortho” (external provider). She agrees with the high risk of complications and will see him at her office in 30 minutes.
I applied a nonadherent dressing with Coban to the wound.
ASSESSMENT
Right hand injury
Cellulitis right hand
PLAN
After discussion with Dr. “Ortho,” patient’s brother will take him to the orthopedics office now. Referral has been placed.
Orders Placed in the Encounter
3-view radiographs of the right hand
Facility-Administered Encounter Medications
None
Medications Prescribed During the Encounter
None
CHALLENGE: What is the appropriate E/M code for this encounter?
Let’s consider this patient encounter using this simplified Elements of Medical Decision Making table to find the appropriate LOS (level of service):1
| 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 | • 1 stable chronic illness • 1 acute, uncomplicated illness • 1 acute, uncomplicated injury | At least 1 of these: • 2 data sources (eg, ordering or reviewing tests) • Independent historian | OTC medication management | 99203 99213 |
| Level 4: Moderate | • 1 or more chronic illnesses with exacerbation • 2 stable chronic illnesses • 1 undiagnosed new problem • 1 acute illness with systemic symptoms | At least 1 of these: • 3 data sources (eg, ordering or reviewing tests); can include independent historian • Independent interpretation of test results • Discussion of management or test interpretation | • Prescription drug management • Significant social determinants of health | 99204 99214 |
| Level 5: High | • Severe illness with exacerbation • Threat to life or bodily function | At least 2 of these: • 3 data sources (eg, ordering or reviewing tests); can include independent historian • Independent interpretation of test results • Discussion of management or test interpretation | Severe without emergent treatment | 99205 99215 |
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.
Number and Complexity of Problems Addressed
Patient chief complaint is a right-hand injury/wound with a probable infection. This would meet the criteria of “acute, complicated injury” due to infection, which is Moderate, Level 4.
Amount and/or Complexity of Data to be Reviewed and Analyzed
X-ray of the right hand was performed in the clinic; however, we cannot use this towards this category because it is a separately reported service. The clinician did call an external provider, Dr. “Ortho,” to discuss the management of this patient. This meets the criteria for the 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 injury. An urgent referral was placed to an orthopedic provider. This would meet the criteria for Moderate, Level 4 risk.
Considerations
Low, Level 3 includes acute, uncomplicated injury; routine contusions, bursitis, strains, and sprains would be considered uncomplicated. Moderate, Level 4, is an acute, complicated injury; examples of complicated injuries include (but are not limited to) infected wounds, dislocations with signs of nerve impingement, head injury in patients aged >65 years, multiple injuries, and an extensive injury with multiple treatment options.
2 of the 3 Elements of Medical Decision Making must be met when choosing the level of service. This encounter met Level 4 criteria in all 3 of the categories, so the correct E/M code is 99204.
1American Medical Association. CPT® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. Accessed September 10, 2022. Available at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-codechanges.pdf
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Last Updated on February 20, 2023
