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