Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
PRESENTATION:
25-year-old established female patient presents with left lower abdominal/pelvic pain for 3 days. The pain is a 5 and is constant and described as an “ache.” She has had minimal abnormal vaginal discharge. She has taken OTC ibuprofen with little relief. She is sexually active with one partner and uses oral contraceptive pills for contraception. She denies fevers, chills, nausea, vomiting, dysuria, flank pain, diarrhea, or constipation.
Past Medical History
- Endometriosis
- Allergic rhinitis
Current Medications
- OTC Allegra® 60 mg daily PRN
- OTC ibuprofen
Drug Allergies
- None
EXAMINATION
- BP: 118/74 mm Hg
- HR: 98 beats/min
- RR:16 breaths/min
- Temp: 99.8° F
- SPO2: 98%
- A&OX3, no acute distress, vital signs are stable
- HEENT: Normocephalic, PERRLA
- Neck: Supple, no adenopathy
- Lungs: Clear to auscultation bilaterally
- Heart: Regular rate; no murmur, rubs, or gallops
- Abdomen: Soft, mild TTP lower left quadrant; no flank pain, guarding, rebound or rigidity; bowel sounds × 4
- Skin: No cyanosis, no rash, good skin turgor
- Pelvic exam: No external lesions or rash. There is left adnexal tenderness without guarding or rebound. There is mild abnormal yellow, mucopurulent vaginal discharge along with a friable cervix. Bimanual pelvic examination is positive for cervical motion tenderness, left adnexal tenderness, but no uterine tenderness.
ASSESSMENT
- Left lower abdominal pain
- Left pelvic pain – suspect PID
Medications Prescribed During the Encounter
- Ceftriaxone 500 mg IM × 1 dose
- Doxycycline 100 mg PO bid × 14 days
- Metronidazole 500 mg PO bid × 14 days
Labs Ordered During the Encounter
- POC urine pregnancy test is negative
- POC urinalysis is negative
- Gonorrhea/chlamydia NAAT swab sent to lab
- HIV, RPR/VDRL, hepatitis panel sent to lab
PLAN
- OTC Tylenol® PRN pain
- Discussed abstinence or barrier contraception during treatment period
- She will contact her OB/GYN for follow up with 48-72 hours
- She understands if her condition worsens, she will go to the emergency department
- Ceftriaxone 500 mg IM × 1 dose
- Doxycycline 100 mg PO bid × 14 days
- Metronidazole 500 mg PO bid × 14 days
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 lower abdominal/pelvic pain but has normal vital signs and is in no acute distress, which would meet the criteria for Low Complexity (Level 3). If there were systemic symptoms or abnormal vital signs, this may have met the criteria for an acute illness with systemic symptoms (Moderate Complexity, Level 4). With proper documentation, this encounter could meet the criteria for “1 undiagnosed new problem with uncertain prognosis,” which would also be Moderate Complexity (Level 4).
Amount and/or Complexity of Data to be Reviewed and Analyzed
There were multiple labs ordered. Three or more labs meet the Moderate Complexity (Level 4) criteria.
Risk of Complications and/or Morbidity or Mortality of Patient Management
The provider prescribed doxycycline and metronidazole. Prescription medication management meets the criteria for Moderate Risk (Level 4).
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 the Complexity of Data and Risk categories, so the correct E/M code is 99214.
1American Medical Association. Evaluation and Management (E/M) Services Guidelines. Accessed January 1, 2023. Accessed September 10, 2023. Available at: http://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
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Last Updated on October 5, 2023
