Coding Challenge: Dental Emergencies in Urgent Care

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


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


  • 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


  • Fever
  • Jaw pain – possible deep space abscess
  • DM Type II
  • History of prostate cancer


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?

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Last Updated on May 30, 2023

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