Coding Challenge: Bronchiolitis in Urgent Care

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

Subjective:

New patient. 22-month-old female with mother. Mom states patient has had fever, cough, “loud breathing,” sinus congestion, and lack of appetite for 2 days. Fever up to 103.1°F.  Fluid intake is decreased. Current medications include ibuprofen.

Current Outpatient Medications

  • OTC Ibuprofen
  • No Known Allergies

Objective:

  • Pulse: 144 beats/min
  • Respiratory rate: 42 breaths/min
  • Temp: 102.5°F
  • SPO2: 91% on room air
  • Weight: 23 lbs.
  • General appearance: Alert but ill appearing child sitting in her mother’s lap.
  • Head: Normocephalic
  • Eyes: PERRLA
  • Ears: Clear without erythema
  • Nose: clear rhinorrhea with drainage
  • Throat: No erythema, no tonsillar hypertrophy or exudates, pale, dry mucous membranes
  • Neck: Supple with no adenopathy
  • Lungs: Use of accessory muscles and occasional grunting noted, wheezing to auscultation bilaterally
  • Heart: Tachycardia; regular rhythm; S1, S2 normal; no murmur, click, rub or gallop
  • Skin: No rash

Recent Results

  • POCT COVID-19 nucleic acid: Negative
  • POCT Influenza nucleic acid: Negative

Assessment:

  • Viral illness
  • Bronchospasm

Orders this encounter:

  • POCT COVID-19 nucleic acid
  • POCT Influenza nucleic acid

Plan:

Discussed diagnosis with the patient’s mother. Due to likelihood of bronchiolitis, with respiratory difficulties, dehydration, and high fever, we have called EMS for safe transport to the emergency department. Mother agrees with transport.

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 LevelaProblems AddressedComplexity of DataRisk of ComplicationsE/M Service
Codes
Level 2:
Straightforward
Minor/self-limitedMinimal/noneMinimal risk99202
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
aLevel is based on 2 out of 3 elements of medical decision making.
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.

Number and Complexity of Problems Addressed

The patient has fever (currently 102.5°F), cough, tachycardia, tachypnea, dehydration, and a low SPO2 of 91%. This child is extremely ill and has a high risk of morbidity from her current condition. This would meet the criteria for an “acute illness with systemic symptoms,” so would be Moderate, Level 4.

Amount and/or Complexity of Data to be Reviewed and Analyzed

2 POCTs were ordered (COVID and influenza). The HPI was provided by the mother (independent historian) which counts as 1 “point.” The 2 POCTs and independent historian meet the criteria for Moderate, Level 4.

Risk of Complications and/or Morbidity or Mortality of Patient Management

The patient is extremely ill and has a high risk of morbidity from her current illness. She has a below-normal SPO2 of 91%, grunting respirations, wheezing, high fever, dehydration, tachypnea, tachycardia, and using accessory muscles to breath. EMS has been called for an appropriate transfer to the emergency department. This would meet the criteria for High, Level 5 risk.

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 2 of the categories (Problems Addressed and Complexity of Data), 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

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