Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
A 44-year-old female new patient presents to urgent care complaining of symptoms that began
2 days ago and include a nonproductive cough, fever, nasal congestion, nausea and vomiting. Pertinent
negatives include no chest pain, headaches, or orthopnea. Her symptoms are alleviated by OTC cough suppressant. She has no history of COPD.
Presentation
Review of Systems:
- Constitutional: Positive for malaise/fatigue. Negative for chills.
- HENT: Positive for congestion
- Eyes: Negative
- Cardiovascular: Positive for dyspnea on exertion. Negative for chest pain.
- Respiratory: Positive for cough. Negative for shortness of breath.
- Skin: Negative
- Musculoskeletal: Negative for myalgias
- Gastrointestinal: Positive for nausea. Negative for diarrhea and vomiting.
- Neurological: Negative for headaches
Past Medical History:
- Anemia
- Bronchitis
Social History:
- Nonsmoker
- Alcohol use (1-2 drinks per week)
Objective
- BP 144/79 mm Hg
- HR: 109 beats/min, regular
- RR: 24 breaths/min
- Temp: 102.6 °F
- SpO2: 95%
- Height: 5′ 1″
- Weight: 119 lb
- BMI: 22.48 kg/m²
Physical Exam:
- Constitutional:
- General: She is not in acute respiratory distress.
- Appearance: She is well-developed. She is mildly ill-appearing.
- HENT:
- Nose: Mucosal edema present. No congestion.
- Mouth/Throat:
- Mouth: Mucous membranes are moist.
- Pharynx: No posterior oropharyngeal erythema.
- Neck:
- Vascular: No JVD.
- Cardiovascular:
- Rate and rhythm: Tachycardic; regular rhythm
- Heart sounds: Normal heart sounds
- Musculoskeletal:
- Right lower leg: No edema
- Left lower leg: No edema
- Pulmonary:
- Effort: Pulmonary effort is normal. No respiratory distress.
- Breath sounds: No stridor. Examination of the lung fields reveals rhonchi. Rhonchi (diffuse mild rhonchi bilaterally; coarse cough) present. No wheezing or rales.
- Skin:
- General: Skin is warm and dry.
- Neurological:
- General: No focal deficit present.
- Mental Status: She is alert.
- Psychiatric:
- Behavior: Behavior normal.
Imaging last 24 hours:
- Radiology interpretation
- 2-view CXR shows no infiltrate or cardiomegaly. No mass or pneumothorax.
Lab orders placed this encounter:
- POC multiplex test for Flu A/B and SARSCoV-2; positive for influenza type A
- POC test for RSV; negative.
Impression/Plan
- Influenza Type A
- Discussed the risk and benefits of taking antivirals, including side effects and allergic reactions.
- Take oseltamivir as prescribed.
- Take ondansetron as prescribed.
- Follow-up with PCP this week.
- Go to the ED if symptoms worsen.
- Take OTC acetaminophen PRN for fever and muscle/body aches.
- Increase fluids and get plenty of rest.
CHALLENGE: What is the appropriate E/M code for this encounter?
Let’s consider this patient encounter using this simplified Elements of Medical Decision Making table to find the appropriate LOS (level of service):1
| 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 | • 1 stable chronic illness • 1 acute, uncomplicated illness • 1 acute, uncomplicated injury | At least 1 of these: • 2 data sources (eg, ordering or reviewing tests) • Independent historian | OTC medication management | 99203 99213 |
| Level 4: Moderate | • 1 or more chronic illnesses with exacerbation • 2 stable chronic illnesses • 1 undiagnosed new problem • 1 acute illness with systemic symptoms | At least 1 of these: • 3 data sources (eg, ordering or reviewing tests); can include independent historian • Independent interpretation of test results • Discussion of management or test interpretation | • Prescription drug management • Significant social determinants of health | 99204 99214 |
| Level 5: High | • Severe illness with exacerbation • Threat to life or bodily function | At least 2 of these: • 3 data sources (eg, ordering or reviewing tests); can include independent historian • Independent interpretation of test results • Discussion of management or test interpretation | Severe without emergent treatment | 99205 99215 |
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.
Number and Complexity of Problems Addressed
Patient complaints are cough, fever, dyspnea on exertion, nausea, and body aches. This would fall under “1 acute illness with systemic symptoms,” which is Level 4.
Amount and/or Complexity of Data to Be Reviewed and Analyzed
The clinician ordered a POC multiplex test for influenza and SARS-CoV-2 and a separate test for
RSV. The multiplex test is billed as a single test, so complexity of data is Level 3.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Oseltamivir and ondansetron were prescribed. Prescription drug management meets the criteria
for Level 4.
2 of the 3 Elements of Medical Decision Making must be met when choosing your level of service. This encounter met Level 4 criteria in 2 of the categories (Problems Addressed and Risk), so the correct E/M code is 99214.
1American Medical Association. CPT® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. Accessed September 10, 2022. Available at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-codechanges.pdf
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