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.
PAST MEDICAL HISTORY
- Hypercholesterolemia
- Tobacco use – 45 pack/year history
CURRENT MEDICATIONS
- Atorvastatin 20 mg once daily
- OTC ibuprofen
DRUG ALLERGIES
- Penicillin, which causes a rash
OBJECTIVE
- 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.
CLINIC ORDERS
- 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.
ASSESSMENT
- Fatigue
- Headache
- Epigastric abdominal pain
- History of COVID-19
PLAN
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?
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 fatigue, insomnia, myalgias, and headache. He has a lower-than-expected blood pressure for a 66-year-old man and an elevated heart rate and low pulse oximetry. He is pale and diaphoretic. He could have an acute illness that poses a threat to life or bodily function. This would be Level 5 (High) in Problems Addressed.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The clinician ordered 3 POC tests (CBC, UA, blood glucose) and an EKG. If your healthcare system bills for the professional interpretation of the EKG, you cannot count it as a point. However, in this case, we have still met the criteria for Level 4 (Moderate) in Complexity of Data.
Risk of Complications and/or Morbidity or Mortality of Patient Management
This patient was sent to the emergency department for further evaluation/management due to a high risk of mortality/morbidity. He is at high risk of a very bad outcome. This is Level 5 (High) in Risk of Patient Management.
Two of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 5 criteria were met in the Problems Addressed and Risk categories, so the correct E/M code is 99205.
| 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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Last Updated on March 13, 2024
