Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION
38-year-old male established patient presents to the urgent care clinic with a 1-day history of nausea, vomiting, diarrhea, chills, and generalized abdominal pain. He states that his symptoms started with chills, nausea, and vomiting, then expanded with diarrhea and abdominal pain. The abdominal pain is described as crampy and dull. He rates the pain as 3 on a scale of 1 to 10. No bloody emesis or bloody stools. He has vomited × 2 today and had 2 episodes of watery diarrhea. No recent travel or change in diet. No chest pain, dyspnea, dizziness, rash, or headache.
OBJECTIVE
- BP: 130/78 mm Hg
- HR: 88 beats/min Reg
- RR: 16 breaths/min
- Temp: 98.2°F
- SpO2: 96%
- General appearance: Alert and oriented × 3, no acute distress
- Head: normocephalic, atraumatic
- Eyes: PERRLA, EOMI, no scleral icterus
- Ears: TMs intact, no drainage or erythema
- Mouth: Moist, no erythema, or exudates
- Neck: Supple, no JVD or adenopathy
- Lungs: CTAB, no wheezes, rhonchi, or rales
- Heart: RRR without murmur
- Abdomen: Bowel sounds × 4, mild TTP generalized but mostly left lower quadrant, no guarding, rebound, or rigidity
- Skin: No cyanosis, rash, or wounds; good skin turgor
Test ordered during this encounter:
- POC urinalysis: No abnormalities
- POC complete blood count: No abnormalities
- Flat and upright abdominal radiographs: I viewed the 2-view abdominal radiographs and found no air-fluid levels or apparent bowel obstruction.
PLAN
Likely gastroenteritis, but I have also considered diverticulitis, inflammatory bowel disease, small bowel obstruction, and appendicitis. Treatment options include antiemetics, imaging studies, and maintaining hydration, and rest. He would like to try antiemetics and hydration today. I prescribed ondansetron 4 mg by mouth, 3 times a day as needed, #21 tablets.
He will follow up at our clinic or with his primary care provider in 2 days. He will return sooner, or go to the emergency department, if symptoms worsen. We discussed red flag symptoms to include fever >101°F, bloody stools or bloody emesis, severe abdominal pain, or dizziness. If he develops any of these symptoms, he will call 911. He can call with any questions or concerns.
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 complaint includes abdominal pain, chills, nausea, vomiting, and diarrhea. The clinician did not document a specific diagnosis. This would meet the criteria for an “undiagnosed new problem with uncertain diagnosis,” which is Moderate, Level 4.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician ordered flat and upright abdominal radiographs, POC complete blood count, and a POC urinalysis. The clinician’s healthcare system bills for the technical and professional component of radiographs, so the radiograph interpretation does not count towards this encounter. The 2 POC tests meet the criteria for Low, Level 3.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Ondansetron was prescribed. This meets the criteria of prescription drug management for Moderate, Level 4.
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 2 categories (Problems Addressed and Risk of Patient Management), so the correct E/M code is 99214.
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