Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION
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
OBJECTIVE
- 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.
ASSESSMENT
- Gastrointestinal bleed
- Anemia
- Epigastric abdominal pain
PLAN
- 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?
Let’s consider this patient encounter using a simplified Elements of Medical Decision Making table to find the appropriate LOS.1
Number and Complexity of Problems Addressed
The patient complains of dizziness, vague abdominal pain, loss of appetite, and fatigue. He has a lower-than-expected blood pressure for a 56-year-old man and an elevated heart rate and slightly low pulse oximetry. He is pale and diaphoretic. He could have an acute illness that poses a threat to life or bodily function. This would be Level 5 (High) in Problems Addressed.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician ordered 4 POC tests (FOBT, CBC, UA, blood glucose) and an ECG. If your healthcare system bills for the professional interpretation of the ECG, you cannot count it as a point. This would still meet the criteria for Level 4 (Moderate) in Complexity of Data.
Risk of Complications and/or Morbidity or Mortality of Patient Management
This patient has an acute illness (GI blood loss) with a very low hemoglobin level and is showing signs of hypovolemic shock. He is at high risk of a very bad outcome. This is a Level 5 (High) in Risk of Patient Management.
Two of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 5 criteria were met in the Problems Addressed, Complexity of Data, and Risk categories, so the correct E/M code is 99205.
| 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 | One of these: • ≥2 self-limited/minor problems • 1 stable chronic illness • 1 acute uncomplicated illness or injury • 1 stable acute illness • 1 acute uncomplicated illness or injury requiring hospital care | Meets at least 1 of these categories: Category 1: Any 2 of these: • Review of external notes from unique source • Review of test results from unique source • Order of unique test Category 2: • Assessment of independent historian | Low risk • Example: OTC medication management | 99203 99213 |
| Level 4: Moderate | One of these: • ≥1 chronic illness with exacerbation • ≥2 stable chronic illnesses • 1 undiagnosed new problem (uncertain prognosis) • 1 acute illness with systemic symptoms • 1 acute complicated injury | Meets at least 1 of these categories: Category 1: Any 3 of these: • Review of external notes from unique source • Review of test results from unique source • Order of unique test • Assessment of independent historian Category 2: Interpretation of test performed by external source Category 3: Discussion of test or management with external clinician | Moderate risk • Examples: Prescription drug management; significant social determinants of health | 99204 99214 |
| Level 5: High | • ≥1 chronic illness with severe exacerbation or progression | Meets at least 2 of these categories: Category 1: Any 3 of these: • Review of external notes from unique source • Review of test results from unique source • Order of unique test • Assessment of independent historian Category 2: Interpretation of test performed by external source Category 3: Discussion of test or management with external clinician | High risk • Example: Decision to escalate to hospital care | 99205 99215 |
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.
1American Medical Association. Evaluation and Management (E/M) Services Guidelines. Accessed January 1, 2023. Accessed October 10, 2023. Available at: http://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
For an in-depth review of this topic, access the full course.
Last Updated on February 13, 2024
