Coding Challenge: Community-Acquired Pneumonia in Urgent Care

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


New patient presents with cough and fever.

44-year-old female complains of cough. The current episode started yesterday. The cough is nonproductive. Possible exposure to COVID-19 3 days ago at work. Associated symptoms include fever, dyspnea on exertion, malaise/fatigue, body aches, nasal congestion, and nausea. Pertinent negatives include no chest pain, headaches, or orthopnea. Her symptoms are alleviated by OTC cough suppressant. There is no history of COPD.  

Review of Systems

  • Constitutional: Positive for malaise/fatigue. Negative for chills.
  • HENT: Positive for congestion
  • Eyes: Negative
  • Cardiovascular: Positive for dyspnea on exertion. Negative for chest pain.
  • Respiratory: Positive for cough. Negative for shortness of breath at rest.
  • Skin: No rash
  • Musculoskeletal: Negative for myalgias
  • Gastrointestinal: Positive for nausea. Negative for diarrhea and vomiting.
  • Neurological: Negative for headaches

Past Medical History

  • Anemia  
  • Bronchitis  

Social History

  • Tobacco Use
    • Smoking status: Current smoker
    • Packs/day: 0.50 X 20 years
    • Types: Cigarettes
  • Substance Use Topics
    • Alcohol use: No


  • BP 144/79 (BP location: right arm; patient position: sitting)
  • Pulse 119
  • Temp 102.6 °F (Tympanic)
  • Resp 24
  • Ht 5′ 1″ (1.549 m)
  • Wt 119 lb (54 kg)
  • SpO2 95%
  • BMI 22.48 kg/m²

Physical Exam

  • Constitutional:  
    • General: She is not in acute respiratory distress.
    • Appearance: She is well-developed. She is mildly ill-appearing.
  • HENT:
    • Nose: Mucosal edema present. No congestion.
    • Mouth/Throat:
      • Mouth: Mucous membranes are moist
      • Pharynx: No posterior oropharyngeal erythema
  • Neck:
    • Vascular: No JVD
  • Cardiovascular:
    • Rate and rhythm: Tachy rate and regular rhythm
    • Heart sounds: Normal heart sounds
  • Musculoskeletal:
    • Right lower leg: No edema
    • Left lower leg: No edema
  • Pulmonary:
    • Effort: Pulmonary effort is normal. No respiratory distress.
    • Breath sounds: No stridor. Examination of the lung fields reveals rhonchi. Rhonchi (diffuse mild rhonchi bilaterally; coarse cough) present. Rales right lung field. No wheezing.
  • Skin:
    • General: Skin is warm and dry.                           
  • Neurological:
    • General: No focal deficit present.
    • Mental Status: She is alert.
  • Psychiatric:
    • Behavior: Behavior normal

Radiology interpretation

I personally viewed the 2-view CXR, which shows an infiltrate in the right middle lobe. No mass or pneumothorax.

Lab orders placed this encounter

  • POCT COVID-19 test is negative
  • POCT Influenza test is negative for type A & B


  1. Right middle lobe pneumonia
  2. Suspected exposure to COVID-19

See specific instructions and follow up as given to patient/caregiver below. We discussed the risk and benefits of taking Augmentin including side effects and allergic reactions.

Discussed with patient the need for smoking cessation. She quit about 3 years ago with Wellbutrin® for six months. She will contact her PCP for further discussion/management of tobacco use.

Follow-up with PCP this week. Go to the ED if symptoms worsen. Take OTC acetaminophen PRN for fever and muscle/body aches. Increase fluids and plenty of rest.

New Prescriptions

  • Albuterol sulfate HFA 108 (90 Base) MCG/ACT inhaler
    • Commonly known as: PROVENTIL HFA
    • Two puffs, inhalation, every 6 hours as needed
  • Augmentin 875 mg
    • Take one pill by mouth twice daily for 10 days

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
Level 2:
Minor/self-limitedMinimal/noneMinimal risk99202
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
Level 4: Moderate• 1 or more chronic illnesses
with exacerbation
• 2 stable chronic illnesses
• 1 undiagnosed new problem (uncertain prognosis)
• 1 acute illness with systemic
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
• Significant social
determinants of health
Level 5: High• Severe illness with
• 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
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 complains of fever, cough, dyspnea on exertion, fatigue, nausea, and body aches. This would meet the criteria for an “acute illness with systemic symptoms.” This is Moderate, Level 4.

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

Two point-of-care tests were ordered (COVID and influenza) along with a chest x-ray. The chest x-ray does not count towards the criteria in this category because this urgent care clinic bills for either the technical or professional component. The 2 point-of-care tests meet the criteria for Low, Level 3.

NOTE: If the company or facility does not bill for any component of the x-ray, then it would count as an additional data point for this category.

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

Prescription medications (Augmentin and Albuterol) were prescribed. This would meet the criteria for Moderate, Level 4 risk.

2 of the 3 Elements of Medical Decision Making must be met when choosing the level of service. Level 4 criteria were met in the Problems Addressed and Risk categories, 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:

For an in-depth review of this topic, access the full course.

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