Coding Challenge: Pediatric Community-Acquired Pneumonia in Urgent Care

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


6-year-old girl, new patient, complains of fever and cough. Dad is in the room and providing the HPI. Symptoms started yesterday. The cough is nonproductive. Possible exposure to COVID-19 2 days ago at school. Associated symptoms include fatigue, body aches, nasal congestion, and loss of appetite. Pertinent negatives include no chest pain, headaches, or vomiting. Her fever is alleviated by OTC acetaminophen.

Review of Systems

  • Constitutional: Positive for malaise/fatigue. Negative for chills.
  • HEENT: Positive for congestion.
  • Eyes: Negative
  • Cardiovascular: Negative for chest pain.
  • Respiratory: Positive for cough. Negative for shortness of breath.
  • Skin: No rash
  • Gastrointestinal: Negative for diarrhea and vomiting.
  • Neurological: Negative for headaches.

Past Medical History

  • None

  Current Medications

  • OTC acetaminophen

Drug Allergies

  • None known


BP 112/69 (BP Location: Right arm, Patient Position: Sitting) | Pulse 129 | Temp 102.2 °F (Tympanic) | Resp 28 | SpO2 94% | 52 pounds

Physical Exam


   General: She is not in acute respiratory distress.

   Appearance: She is mildly ill-appearing.


   Nose: Mucosal edema present. No congestion.


   Mouth: Mucous membranes are moist.

   Pharynx: No posterior oropharyngeal erythema.


   Rate and Rhythm: Tachy rate and regular rhythm.

   Heart sounds: Normal heart sounds.


   Right lower leg: No edema.

   Left lower leg: No edema.


   Effort: Pulmonary effort is normal. No respiratory distress.

   Breath sounds: No stridor. Examination of the lung fields reveals rhonchi. Rhonchi (Diffuse mild rhonchi R>L. Coarse cough.) present. Rales right lung field. No wheezing.


   General: Skin is warm and dry.                                                   


   General: No focal deficit present.

   Mental Status: She is alert.


   Behavior: Behavior normal.

Radiology interpretation

I personally viewed the two view CXR which shows an infiltrate in the right middle lobe. No mass or pneumothorax.

Lab orders placed this encounter:

POCT COVID test is negative

POCT Influenza test is negative for type A & B.


  1. Right middle lobe pneumonia
  2. Exposure to COVID

See specific instructions and follow up as given to patient/caregiver below. We discussed the risk and benefits of taking Amoxil and Zithromax including side effects and allergic reactions.

Follow-up with your pediatrician this week. Go to the ED if symptoms worsen. Take OTC Tylenol PRN for fever and body aches. Increase fluids and plenty of rest.

New Prescriptions

  • Amoxil (400 mg/5 mL) 2¾ teaspoons BID for 10 days
  • Zithromax (200 mg/5 mL) 1 teaspoon PO day 1 and then ½ teaspoon PO days 2-5

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

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