Coding Challenge: Dizziness in Urgent Care

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


56-year-old established male new patient presents to your urgent care with a chief complaint of dizziness. Symptoms started when he awoke about 24 hours ago. He went to work today at his landscaping business, but the dizziness worsened. He describes the dizziness as mostly constant and worsens with activities. Associated symptoms include diaphoresis, vague abdominal pain, loss of appetite, and fatigue. He takes OTC ibuprofen “everyday” for his “chronic back pain.” No CP, SOB, rash, or vomiting.

Past Medical History

  • None

Current Medications

  • OTC ibuprofen

Drug Allergies

  • Penicillin, which causes a rash


  • BP: 101/83 mm Hg
  • HR: 136 Reg
  • RR: 16
  • Temp: 97.9°F
  • SPO2: 93%
  • Ht: 5’9”
  • Wt: 163 lbs
  • A&OX3, laying on exam table, no acute respiratory distress, but he does appear pale and is mildly diaphoretic.
  • HEENT: PERRLA, no scleral icterus, pale conjunctiva. Oropharynx: clear, no erythema or exudates. TMs clear without erythema. 
  • Neck: No adenopathy or JVD
  • Lungs: CTAB, no rales, rhonchi, or wheezing
  • Heart: Tachycardic rate without murmur
  • Abdomen: BSX4, no guarding, but there is vague, epigastric abdominal pain. A fecal occult blood test is positive and there is black, tarry stool on gloved finger.
  • Skin: Pale, cool, and clammy. No rash on the extremities.  Capillary refill is delayed at 4 seconds.

Clinic Orders

  • POC fecal occult blood test is positive.
  • POC urinalysis is negative for leukocytes, blood, glucose, ketones, and nitrites.
  • POC CBC shows a hemoglobin level of 6.8 g/dl and the hematocrit is 21%
  • POC blood glucose is 87 mg/dL
  • ECG shows sinus tachycardia. No Q waves, ST-T abnormalities, or other abnormalities.


  • Gastrointestinal bleed
  • Anemia
  • Epigastric abdominal pain


  • Oxygen via nonrebreather mask at 12LPM, IV lactated Ringers, monitor ECG until EMS arrives.
  • The patient will be transferred to the emergency department by EMS for further assessment and intervention.

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

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Last Updated on February 13, 2024

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