Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
43-year-old established male patient presents to urgent care with a chief complaint of low-grade fever, fatigue, myalgias, sore throat, swollen glands, headache, and loss of appetite. The symptoms started about 2 weeks ago. He has taken OTC ibuprofen with relief of his fever. No CP, SOB, rash, abdominal pain, dizziness, or diarrhea/vomiting. He states he had sexual intercourse with a new female partner about 4 or 5 weeks ago and is concerned for sexually transmitted infections. He denies any history of STIs.
PAST MEDICAL HISTORY
- None
CURRENT MEDICATIONS
- OTC ibuprofen
DRUG ALLERGIES
- Penicillin, which causes a rash
OBJECTIVE
- BP: 141/83 mm Hg
- HR: 109 beats/min Reg
- RR: 16 breaths/min
- Temp: 100.9°F
- SPO2: 98%
- Height: 6’0”
- Weight: 188 lbs
- A&O×3, sitting on exam table, no acute respiratory distress, looks mildly ill
- HEENT: PERRLA, no scleral icterus, conjunctiva without erythema. Oropharynx: Clear, no erythema or exudates. 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
- Abdomen: BS×4, no rebound or guarding
- Skin: Pale, cool, and clammy. No rash on the extremities.
CLINIC ORDERS
- POC CBC is WNL
- POC mononucleosis test is negative
- Rapid strep test is negative
- POC blood glucose is 87 mg/dl
- Send-out labs:
- Urine gonorrhea/chlamydia
- CMP
- HIV antigen/antibody
- Hepatitis B antibody/surface antigen
- Hepatitis C antibody
- RPR
- EKG shows sinus tachycardia. No Q waves, ST-T abnormalities, or other abnormalities.
ASSESSMENT
- Fever
- Viral illness
PLAN
Discussed with the patient possible causes of his symptoms to include STIs, viral illnesses, and other systemic illnesses. We discussed the laboratory orders and the need for close follow-up after labs have been reviewed. If his symptoms worsen, he will go to the emergency department for further evaluation. He can call us with any questions or concerns. He will continue to take OTC ibuprofen for fever >100.5°F. Increase fluids and rest.
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 low-grade fever, fatigue, myalgias, sore throat, swollen glands, headache, and loss of appetite. He has a fever, tachycardia, and other systemic symptoms, meeting the criteria for an acute illness with systemic symptoms. This meets the criteria for Moderate, Level 4 in the Problems Addressed category.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician ordered 4 point-of-care tests (complete blood count, streptococcal screen, mononucleosis spot test, blood glucose), multiple send-out lab tests, and an EKG. This meets the criteria for Moderate, Level 4 in the Complexity of Data category. (Note that if your healthcare system bills for the professional interpretation of the EKG, you cannot count it as a point in this category.)
Risk of Complications and/or Morbidity or Mortality of Patient Management
This patient was not prescribed medication, but he was informed to take OTC ibuprofen. This meets the criteria for Low, Level 3 in the Risk/Patient Management category.
Two of the three Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 4 criteria were met in the Problems Addressed and Risk categories, so the correct E/M code is 99214.
| 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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