Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
Subjective
Sore Throat: 24-year-old female who complains of a sore throat. Symptoms began 2 days ago. Pain is of moderate severity. Fever is absent. Other associated symptoms have included pain while swallowing, swollen glands, and feeling that her right tonsil is swollen. Fluid intake is good. There has not been contact with an individual with known strep. Current medications include ibuprofen.
Current Outpatient Medications:
- norethindrone-ethinyl estradiol-ferrous fumarate (LOESTRIN-FE,MICROGESTIN-FE,JUNEL-FE,LARIN-FE) 1-20 MG-MCG per tablet 1 tablet, Oral, Daily
- OTC Ibuprofen
No Known Allergies
Objective
BP 147/87 (BP Location: Left arm; Patient position: Sitting) | Pulse 101 | Temp 99.5 °F (37.5 °C) (Tympanic) | Resp 16 | Ht 5′ 5″ (1.651 m) | Wt 250 lb (113.4 kg) | LMP 08/24/2022 | SpO2 99% | BMI 41.60 kg/m²
- General appearance: Alert, cooperative and no distress, obese
- Head: Normocephalic
- Eyes: PERRLA EOMI
- Ears: Clear without erythema
- Nose: Without congestion or drainage
- Throat: marked erythema, tonsillar hypertrophy, 2+, exudates present and mucous membranes moist
- Neck: Supple with mild tender bilateral anterior cervical nodes
- Lungs: clear to auscultation bilaterally
- Heart: normal, regular rhythm, S1, S2 normal, no murmur, click, rub or gallop
- Skin: Skin color, texture, turgor normal. No rashes or lesions
Recent Results (from the past 14 hours)
- POCT CoVid-19 nucleic acid
- Collection Time: 08/24/22 9:52 AM
- Negative
- POCT Strep Nucleic Acid
- Collection Time: 08/24/22 9:53 AM
- Positive
- POCT INFECTIOUS MONONUCLEOSIS ANTIBODY
- Collection Time: 08/24/22 10:52 AM
- Negative
Assessment
Strep Pharyngitis, Primary: J02.0
Orders this encounter:
- POCT CoVid-19 nucleic acid
- POCT Strep Nucleic Acid
- POCT INFECTIOUS MONONUCLEOSIS ANTIBODY
Plan:
1. Discussed diagnosis with patient. Stressed fluid hygiene hydration. Push comfort measures. Follow-up with PCP in 3 to 4 days if not improved or sooner if worsen.
2. Medication changes and new medications: Augmentin 875 mg BID for 10 days. OTC NSAID PRN pain.
3. Follow up in about 1 week, or if symptoms worsen or fail to improve, or with primary care provider.
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 • 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
The patient complaint is pharyngitis. This would fall under “1 acute, uncomplicated illness or injury,” which is Level 3.
Amount and/or Complexity of Data to be Reviewed and Analyzed
In this case, the clinician ordered a POCT strep test, a COVID test, and a Monospot. This would qualify as meeting the criteria for Category 1 (ordering of each unique test x 3) in the Moderate section, which is Level 4.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Augmentin was prescribed. Prescription drug management would meet the criteria for Level 4.
2 of the 3 Elements of Medical Decision Making must be met when choosing your level of service. This encounter met Level 4 criteria in 2 of the categories (Data and Risk), 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
For an in-depth review of this topic, access the full course.
Last Updated on February 20, 2023
