Coding Challenge: Hand Injury in Urgent Care

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


23 y/o male patient with C/C of right-hand injury and wound. He is a new patient. He states he was in a fight 6 days ago and punched another male. He states he has a wound to the right hand, which is now very painful and red. He has also noted greenish drainage. He is right-handed. Prior treatment includes bacitracin and ice; he has taken Ibuprofen for the pain, but says it does not help.  

Past Medical History


Current Medications

OTC Ibuprofen

OTC Bacitracin

Drug Allergies



BP 116/82

HR 88Reg

RR 14

SPO2 99%

Temp 98.2°F

General: A&OX3, NAD, does not appear ill

HEENT: normocephalic, atraumatic, PERRLA

Resp: CTAB

Heart: RRR without murmur

Extremities: Right hand has a 2 cm laceration overlying the third MCP joint with surrounding erythema 4 cm X 5 cm. No obvious drainage currently. Very limited ROM due to pain. Good sensation and capillary refill distally.

3-view radiographs were taken of the right hand. I personally viewed the radiographs and found no acute fracture or dislocation. 

I contacted and discussed the management with Dr. “Ortho” (external provider). She agrees with the high risk of complications and will see him at her office in 30 minutes.

I applied a nonadherent dressing with Coban to the wound. 


Right hand injury

Cellulitis right hand


After discussion with Dr. “Ortho,” patient’s brother will take him to the orthopedics office now. Referral has been placed.

Orders Placed in the Encounter

3-view radiographs of the right hand

Facility-Administered Encounter Medications


Medications Prescribed During the Encounter


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

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Last Updated on February 20, 2023

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