Coding Challenge: HIV in Urgent Care

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.


  • None


  • OTC ibuprofen


  • Penicillin, which causes a rash


  • 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.  


  • 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.


  • Fever
  • Viral illness


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?

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