Coding Challenge: Pelvic Inflammatory Disease in Urgent Care

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?

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Last Updated on October 5, 2023

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