Coding Challenge: Pediatric Orthopedic Injury in Urgent Care

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


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


  • 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.


Supracondylar fracture, right humerus


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?

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