Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
SUBJECTIVE:
12-year-old female, new patient, presents with a chief complaint of right elbow pain/upper arm pain after a fall 1 hour ago. She is a gymnast and was performing a back tuck on the balance beam when she lost her balance and fell backwards. She denies a loss of consciousness, chest pain, or shortness of breath. Her only complaint is severe pain to her right elbow/upper arm. Her mother is with her and providing part of the history of present illness due to the patient crying from the pain. She has not taken any medication for the pain. She does have a large ice pack wrapped in an elastic bandage on the right elbow.
Current Outpatient Medications: None
Allergies: None
OBJECTIVE:
- BP: 128/74
- Resp: 26
- SpO2: 97%
- Temp: 98.5 °F
- Pulse: 129 Reg
General appearance: Alert, cooperative, crying, appears very uncomfortable, and has a large ice pack and wrap on the right elbow.
- HEENT: Atraumatic, PERRL
- Neck: Soft, no tenderness to palpation, FAROM
- Right arm: After removing the ice pack and wrap, there is soft tissue swelling and severe tenderness to palpation of the right distal humerus. There is a gross deformity of the distal humerus/elbow. No wounds but there is mild ecchymosis to the antecubital fossa. Very limited range of motion due to pain. Good distal pulse, motor, and sensory function. Capillary refill in the right fingers is 2 seconds.
- Lungs: Clear to auscultation bilaterally
- Heart: Tachycardia rate, S1, S2 normal, no murmur, click, rub or gallop
3-view right humerus and 2-view right elbow radiographs were ordered. I viewed the radiographs and identified a right impacted supracondylar fracture.
ASSESSMENT
Supracondylar fracture, right humerus
PLAN:
I spoke with the orthopedic provider (Dr. Hammond) on call. He was able to review the radiographs and would like the patient to be seen in the emergency department for further evaluation/surgical intervention.
A long arm splint was used to immobilize her right arm. She had good distal motor, sensory, and pulse after application of the splint.
Her mother drove her to the emergency department in stable condition.
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 (uncertain prognosis) • 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 complains of severe right elbow/arm pain. The radiographs confirm a complicated injury (right supracondylar fracture). This would meet the criteria for an acute complicated injury, Moderate Level 4. If the patient had any neurological complications (numbness, tingling) or vascular compromise (cold, pale, weak pulse, delayed capillary refill) this would have met the criteria for an acute injury that poses a threat to life or bodily function, which would be a High, Level 5.
Amount and/or Complexity of Data to be Reviewed and Analyzed
No lab tests were ordered, and no external notes were reviewed, but the clinician did document that an independent historian (the patient’s mother) provided part of the history of present illness. The clinician called and spoke with the orthopedic specialist on call (Dr. Hammond) and documented this “Discussion of Management.” The clinician’s healthcare system only bills for the technical component of the radiographs and NOT the professional component, so the clinician would also be given credit for “Independent Interpretation of Tests” by viewing and documenting the initial radiology reading. This would qualify as meeting the criteria for “Independent Interpretation of Tests” and “Discussion of Management,” resulting in High, Level 5.
Risk of Complications and/or Morbidity or Mortality of Patient Management
The patient was “stable” and sent to the emergency department to be evaluated by an orthopedist. This would meet the criteria for a Moderate, Level 4 risk.
Two of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 4 criteria were met or exceeded in all 3 categories, 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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