Coding Challenge: Acute Joint Pain in Urgent Care

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


64-year-old male, new patient, presents to your urgent care with a chief complaint of acute onset of left knee pain. He states that he has “arthritis” of his left knee, which is being treated by his orthopedic physician. He does state this is a chronic, intermittent problem. No history of knee replacement or any steroid injections. His symptoms started late last night and have progressively worsened this morning. No fever, rash, or other complaints. He denies any trauma but has been working more in the yard recently. He has taken OTC Tylenol® and ibuprofen, which have helped decrease the pain from a 7 to a 5.  

Current Medications

  • OTC ibuprofen and Tylenol®
  • Hydrochlorothiazide 25 mg once daily for HTN

Drug Allergies

  • Bactrim – Rash


  • Time: 10:30 am
  • Temp 98.5°F
  • BP 137/90 mm Hg
  • Pulse 84 Reg
  • Resp 18 
  • SpO2 97%
  • Ht 5′ 11″
  • Wt 220 lbs
  • General appearance: Sitting in a wheelchair, alert, cooperative, appears in pain
  • HEENT: Normocephalic
  • Lungs: Clear to auscultation bilaterally
  • Heart: Normal, regular rhythm, S1, S2 normal, no murmur, click, rub, or gallop
  • Left knee: There is generalized TTP, mostly to the medial joint line. No erythema or warmth. Limited ROM due to pain. There is a small effusion noted. No rash or wounds.
  • Skin: No rash


  • Acute left knee pain
  • OA left knee
  • 3-view radiographs of the left knee reveal moderate DJD with osteophyte formation. Mild effusion noted. No acute fracture.


  • Meloxicam 7.5 mg once daily PRN pain.
  • Simple ROM exercises as tolerated.
  • Rest, elevation, and ice PRN.
  • If symptoms persist or worsen, he will follow up here or with his orthopedic surgeon.

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

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Last Updated on December 5, 2023

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