Coding Challenge: Angioedema in Urgent Care

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.


  • Asthma


  • Albuterol MDI


  • Penicillin, which causes a rash


  • 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.


  • 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


  • Allergic reaction to strawberries
  • Facial swelling
  • Facial rash
  • Lip swelling


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?

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