Coding Challenge: Long COVID in Urgent Care

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

A 66-year-old established male patient presents to your urgent care with a chief complaint of fatigue, myalgias, headaches, and insomnia. The symptoms started around the time he was diagnosed with COVID-19 about 3 months ago. He was prescribed PaxlovidTM and took it it for the full 5 days. He has not been vaccinated against COVID-19. He has seen his primary care provider for these symptoms with no relief and no improvement. He is here today because the headache is severe (9 out of 10) and he states he feels awful. He has taken OTC ibuprofen with no relief of his headache. He reports no chest pain, shortness of breath, rash, dizziness, or vomiting.


  • Hypercholesterolemia
  • Tobacco use – 45 pack/year history


  • Atorvastatin 20 mg once daily
  • OTC ibuprofen


  • Penicillin, which causes a rash


  • BP 101/83 mm Hg
  • HR 116 Reg
  • RR 20 breaths/min
  • Temp 97.9°F
  • SPO2 91%
  • Ht. 5’9”
  • Wt. 139 lbs
  • A&OX3, sitting on exam table, no acute respiratory distress but he does appear pale and is mildly diaphoretic.
  • HEENT: PERRLA, no scleral icterus, conjunctiva without erythema. Oropharynx: clear, no erythema or exudates. TMs clear without erythema.
  • Neck: No adenopathy or JVD
  • Lungs: CTAB, no rales, rhonchi, or wheezing
  • Heart: Tachycardic rate without murmur
  • Abdomen: BSX4, no rebound or guarding, TTP epigastric region.
  • Skin: Pale, cool, and clammy. No rash on the extremities. Capillary refill is 3 seconds.


  • POC urinalysis is negative for leukocytes, blood, glucose, ketones, and nitrites.
  • POC CBC is WNL
  • POC blood glucose is 127 mg/dl
  • EKG shows sinus tachycardia. No Q waves, ST-T abnormalities, or other abnormalities.


  • Fatigue
  • Headache
  • Epigastric abdominal pain
  • History of COVID-19


Discussed with the patient the need to be thoroughly evaluated in the emergency department. We also discussed possible cardiac or neurological events that could be causing his symptoms. He agrees with transportation via EMS.

Patient with multiple complaints since diagnosis of COVID-19 3 months ago. His headache is severe today with low pulse oximetry and he is pale and diaphoretic. EMS was called to transport to the local emergency department for further evaluation/management.

EMS arrived and transported the patient to the emergency department.

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

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Last Updated on March 13, 2024

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