Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
22-year-old female new patient presents to your urgent care with a chief complaint of facial swelling/rash and lip swelling. The symptoms started shortly after she was eating strawberries about 40 minutes ago. The rash is on the face and neck. Associated symptoms include an “irritated throat.” No CP, SOB, rash, or vomiting. No OTC medications have been given. No history of reactions to eating strawberries in the past.
PAST MEDICAL HISTORY
- Asthma
CURRENT MEDICATIONS
- Albuterol MDI
DRUG ALLERGIES
- Penicillin, which causes a rash
OBJECTIVE
- BP 101/83 mm Hg
- HR 127 beats/min Reg
- RR 22 breaths/min
- Temp 98.2°F
- SPO2 98%
- A&OX3: Sitting on exam table. No acute respiratory distress but she has noticeable facial and lip swelling. She is crying.
- HEENT: PERRLA, no scleral icterus, pale conjunctiva.
- Oropharynx: Uvula is midline, there is mild soft palate swelling but no erythema or exudates. TMs clear without erythema.
- Neck: No adenopathy or JVD
- Lungs: CTAB, no rales, rhonchi, or wheezing
- Heart: Tachycardic rate without murmur
- Abdomen: BSX4, no guarding, but there is vague, epigastric abdominal pain on palpation.
- Skin: Warm and dry. No rash on the extremities but she has hives on the upper back, chest, and upper arms.
CLINIC ORDERS
- Epinephrine 0.4 mg IM given at 1900 hours
- Cetirizine 10 mg PO given at 1905 hours
- O2 nasal cannula at 3 LPM
- IV normal saline TKO rate
ASSESSMENT
- Allergic reaction to strawberries
- Facial swelling
- Facial rash
- Lip swelling
PLAN
The patient will be transferred to the ED by EMS for further assessment and intervention. She was feeling better as EMS arrived and she was transferred to the ED in stable condition.
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
Patient complains of rash, an irritated throat, and facial and lip swelling after eating strawberries. She meets the criteria for “acute illness that poses a threat to life or bodily function.” This would be a high, level 5 in problems addressed.
Amount and/or Complexity of Data to be Reviewed and Analyzed
No labs were ordered. This would be a straightforward, level 2 complexity of data.
Risk of Complications and/or Morbidity or Mortality of Patient Management
This patient has a high-risk condition and was transferred to the ED via EMS. This would be a high, level 5 risk of patient management.
Two 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
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