Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
SUBJECTIVE
56-year-old established male patient presents to urgent care with chief complaints of fever, lower jaw pain and swelling, malaise, and the inability to fully open his mouth. He felt fine last night at 11 p.m. when he went to bed. He awoke earlier than normal this morning with jaw pain and swelling and his temperature was 99.8°F. Symptoms have worsened throughout the day. He has taken OTC ibuprofen with little relief of the pain or fever. No recent dental procedures.
Past Medical History
- DM Type II
- Prostate cancer – currently receiving chemotherapy
- HTN
Current Medications
- Metformin 500 mg BID
- Lisinopril/HCTZ 20/12.5 daily
Drug Allergies
- PCN– rash
OBJECTIVE
- BP 144/88 mm Hg
- HR 104 Reg
- RR 16 breaths/min
- Temp 101.6°F
- SPO2 96%
- Ht. 5’10”
- Wt. 208 lbs.
Physical Exam
- A&OX3, sitting on exam table, appears ill, pale
- HEENT: PERRLA, no corneal injection. Oropharynx: trismus noted. TTP and fullness to the right 2nd premolar area with submandibular swelling.
- Neck: notable swelling to the right submandibular space with TTP. No wounds.
- Lungs: CTAB, no rales, rhonchi, or wheezing
- Heart: Tachy rate without murmur
ASSESSMENT
- Fever
- Jaw pain – possible deep space abscess
- DM Type II
- History of prostate cancer
PLAN
He refused EMS transport to the local ED. He was advised and signed AMA for EMS transport. His son is with him and will take him directly to the ED.
He will continue current medications listed above for his DM and prostate cancer. He has an appointment next week with his endocrinologist and oncology provider to discuss further.
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 (uncertain prognosis) • 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
Male patient complains of of sudden onset of fever, jaw pain and swelling, and malaise. His temperature was 101.6°F and his heart rate was 104 beats/min, meeting the criteria for SIRS (systemic inflammatory response syndrome). This is an acute illness with systemic symptoms, which meets the criteria for Moderate, Level 4.
Amount and/or Complexity of Data to be Reviewed and Analyzed
No lab tests or imaging studies were ordered or reviewed, no independent historian was utilized, and there was no discussion of management with an external source. This meets the criteria for Straightforward, Level 2.
Risk of Complications and/or Morbidity or Mortality of Patient Management
This patient has a high risk of a poor outcome due to the severity of his illness. He went to the ED for further emergent evaluation. This meets the criteria for High, Level 5.
2 of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. This encounter met Level 4 criteria in the Problems Addressed category and Level 5 criteria in the Risk category, 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 May 30, 2023
