Coding Challenge: Electrical Injury in Urgent Care

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

A 22-year-old man, established patient, presents to your urgent care with a chief complaint of right-hand discomfort after “shocking” his hand while plugging in a blender. The symptoms started about 3 hours ago. He has taken OTC ibuprofen with moderate relief of the pain. No CP, SOB, palpitations, rash, dizziness, abdominal pain, right arm paresthesia or vomiting..

PAST MEDICAL HISTORY

  • None

CURRENT MEDICATIONS

  • None

DRUG ALLERGIES

  • No known drug allergies

OBJECTIVE

  • BP 121/84 mm Hg
  • HR 106 Reg beats/min
  • RR 20 breaths/min
  • Temp 98.9
  • SPO2 98%
  • Ht. 5’7”
  • Wt. 178 lbs.
  • A&OX3, sitting on exam table, no acute respiratory distress
  • HEENT: PERRLA, no scleral icterus, conjunctiva without erythema. Fundoscopic exam is negative. Oropharynx:  clear, no erythema or exudates. TMs clear without erythema, TMs intact.
  • Neck: No adenopathy or JVD
  • Lungs: CTAB, no rales, rhonchi, or wheezing
  • Heart: Tachycardic rate without murmur
  • Abdomen: BSX4, no rebound or guarding
  • Neuro: CN II-XII grossly intact
  • Extremities: right arm- no wounds, burns, discoloration, or ecchymosis. FAROM without pain. Skin: warm and dry. No rash on the extremities. Capillary refill is 2 seconds.

CLINIC ORDERS

  • ECG shows sinus tachycardia. No Q waves, ST-T abnormalities, or other abnormalities. No comparison.

ASSESSMENT

  • Right arm pain
  • Electrical injury

PLAN

Stable patient who sustained a low-voltage electrical shock. We monitored his ECG for 60 minutes. I discussed with the patient the symptoms to watch out form, such as chest pain, dyspnea, visual complaints, abdominal pain, and extremity paresthesia. If any of these symptoms arise, he should call 911 and be evaluated in the ED. He will take OTC acetaminophen as needed for pain. He agrees with the plan. He can call our office anytime for any questions or concerns. He will follow up with his primary care provider in the next 3 days.

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

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