Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
A 67-year-old established male patient presents to urgent care with a chief complaint of a nosebleed.
The nosebleed started approximately 6 hours ago while he was sitting at home watching television. He attempted to stop the bleeding by applying pressure, but this was unsuccessful. He reports a history of previous nosebleeds, which are usually controlled with direct pressure. He denies any recent trauma or known injuries. Additionally, he reports no chest pain, dyspnea, dizziness, fatigue, recent upper respiratory infection, or headache. His medical history includes hypertension and pulmonary embolism.
Past Medical History
- Hypertension (2002)
- Pulmonary embolism (2009, 2017)
Current Medications
- Amlodipine, 5 mg once daily
- Warfarin, 5 mg once daily
Drug Allergies
- Penicillin, which causes a rash
OBJECTIVE
- BP: 131/83 mm Hg
- HR: 109 beats/min, regular
- RR: 16 breaths/min
- Temp: 98.9°F
- SpO2: 96%
- Height: 6’ 0”
- Weight: 181 lbs
- General appearance: Alert and oriented × 3, sitting on exam table, no acute respiratory distress, holding a bloody towel to his nose.
- HEENT:
- PERRLA, no scleral icterus, conjunctiva without erythema
- Oropharynx clear, no erythema or exudates, and no blood in the posterior oropharynx
- TMs clear without erythema
- Neck: Nontender cervical adenopathy bilaterally, no JVD or masses
- Lungs: CTAB, no rales, rhonchi, or wheezing
- Heart: Tachycardic rate without murmur
- Skin: Warm and dry, good skin turgor; no rash or petechiae on the extremities
Clinic Orders:
- Point-of-care CBC is within normal limits
- Urgent referral to ENT
- Initial treatment involved holding pressure to the nose for 10 minutes, which was unsuccessful.
A cotton ball saturated with oxymetazoline was then applied, and after 30 minutes, the
bleeding stopped. - I consulted his primary care provider, Dr. Williams, who will see him tomorrow for PT/INR
blood work. I also spoke with Dr. Anderson (ENT), who agrees with the current treatment
and will see the patient in her office tomorrow morning.
ASSESSMENT
- Epistaxis
- History of pulmonary embolism
- Long-term anticoagulant use
PLAN
We discussed the CBC results. I reinforced instructions on what to do if his symptoms return. If the
bleeding recurs and he is unable to control it, he is to go to the emergency department for further
evaluation. He was instructed to call with any questions or concerns. He will follow up tomorrow
with both the ENT specialist and his primary care provider. He is to continue his warfarin as directed
and will have blood work for PT/INR tomorrow.
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
This 67-year-old man presents with epistaxis. While his vital signs are stable, he is tachycardic.
His medical history includes 2 instances of pulmonary embolism, and he is on warfarin. Depending on the patient’s presentation, this case could be classified as 1 chronic illness with exacerbation, an acute illness with systemic symptoms, or an acute uncomplicated illness. In some instances, it could be considered an acute illness that poses a threat to life or bodily function. In this scenario, the patient would likely meet the criteria for an acute uncomplicated illness, which corresponds to a Low, Level 3 for this category.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician consulted with both the patient’s primary care physician and an otolaryngologist regarding management. This consultation meets the criteria for a Moderate, Level 4 complexity of data.
Risk of Complications and/or Morbidity or Mortality of Patient Management
The patient was not prescribed any new medications. He was advised to continue warfarin
at the current dose, and an urgent referral to otolaryngology was placed. This corresponds to a
Moderate, Level 4 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 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
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