Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
Subjective
New patient presents with cough and fever.
44-year-old female complains of cough. The current episode started yesterday. The cough is nonproductive. Possible exposure to COVID 3 days ago at work. Associated symptoms include fever, dyspnea on exertion, malaise/fatigue, body aches, nasal congestion, and nausea. Pertinent negatives include no chest pain, headaches, or orthopnea. Her symptoms are alleviated by OTC cough suppressant. There is no history of COPD.
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:
- Tobacco Use
- Smoking status: Current Some Day Smoker
- Packs/day: 0.50
- Types: Cigarettes
- Substance Use Topics
- Alcohol use: No
Objective
BP 144/79 (BP Location: Right arm, Patient Position: Sitting) | Pulse 109 | Temp 102.6 °F (Tympanic) | Resp 24 | Ht 5′ 1″ (1.549 m) | Wt 119 lb (54 kg) | SpO2 95% | 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:
- POCT COVID test is negative.
- POCT Influenza test is positive for type B. Type A is negative.
Impression/Plan
- Influenza Type B
- Suspected exposure to COVID
- Tobacco abuse
See specific instructions and follow up as given to patient/caregiver below. See prescribed medications, referrals, orders and follow up as listed. Discussed the risk and benefits of taking Tamiflu and Zofran, including side effects and allergic reactions.
Follow-up with your PCP this week. Go to the ED if symptoms worsen. Take OTC Tylenol PRN for fever and muscle/body aches. Increase fluids and 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
In this case, the provider ordered a POCT influenza test and a COVID test. A chest x-ray was ordered and interpreted, but do not include this in your consideration if your company bills for the professional or technical component of the radiograph. This encounter would qualify as meeting the criteria for Category 1 in the Moderate section (ordering of each unique test x 2), which is Level 3.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Tamiflu and Zofran were prescribed. Prescription drug management would meet 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 99204.
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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Last Updated on February 20, 2023
