Coding Challenge: Bronchiolitis in Urgent Care

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


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


  • 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


  • Viral illness
  • Bronchospasm

Orders this encounter:

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


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?

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Last Updated on February 20, 2023

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