Coding Challenge: Red Eye Presentation in Urgent Care

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


34-year-old female, new patient, presents to urgent care with a chief complaint of pain, blurry vision, and redness to the left eye. Her symptoms started about 48 hours ago. She does wear contacts. Pain is of moderate severity. Other associated symptoms include watery drainage and discomfort described as “pressure” to the left eye.  She has taken OTC Tylenol® and ibuprofen, which have not helped.

Current Outpatient Medications

  • OTC ibuprofen and Tylenol®


  • Penicillin: Rash
  • Bactrim: Rash


  • 1:30 p.m.
  • Temp 98.5°F
  • BP 157/97
  • Pulse 109 Reg
  • Resp 22 
  • SpO2 97%
  • Ht 5′ 5″
  • Wt 150 lb
  • General appearance: Alert, cooperative, appears in pain (cupping hands over her left eye and rocking back and forth) in a dimly lit exam room
  • Visual acuity (without correction): Right eye: 20/30; left eye: 20/100
  • Head: Normocephalic
  • Eyes: Left eye – conjunctival injection is generalized, and the pupil is reactive to light. Due to the pain, I administered 2 gtts of tetracaine, which decreased the pain from a 9 to a 6. I was able to perform a thorough examination after applying the tetracaine drops. Fluorescein uptake reveals a branching pattern with terminal bulbs to the inferior aspect of the cornea. There is also mild “cloudiness” to the anterior chamber.
  • Lungs: Clear to auscultation bilaterally
  • Heart: Normal, regular rhythm, S1, S2 normal, no murmur, click, rub or gallop
  • I called Dr. Daniels (Ophthalmologist) and discussed the management of the patient. She recommended an urgent referral to her office today. She did not want me to start any medications at this time since she can see her in 1 hour.


Viral Keratitis


  • Discussed diagnosis with patient.
  • Urgent referral to Ophthalmology (Dr. Daniels) – will see her today at 3:00 pm. The patient’s spouse, William, will drive her to Dr. Daniels’ office.

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 LevelaProblems AddressedComplexity of DataRisk of ComplicationsE/M Service
Level 2:
Minor/self-limitedMinimal/noneMinimal risk99202
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
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
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
• Significant social
determinants of health
Level 5: High• Severe illness with
• 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
aLevel is based on 2 out of 3 elements of medical decision making.
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.

Number and Complexity of Problems Addressed

Patient complaints are pain, blurry vision, redness, and watery discharge from the left eye. With the pain and poor visual acuity she is experiencing, this would meet the definition of 1 undiagnosed new problem with uncertain prognosis, which is Moderate, Level 4. It could be argued that this patient’s complaint and the assessment meet the criteria for 1 acute illness that poses a threat to life or bodily function. With proper documentation, I would agree this could be a Level 5 in this category.

Amount and/or Complexity of Data to be Reviewed and Analyzed

No laboratory tests were ordered, no external notes were reviewed, and no documentation of an independent historian was obtained, but the clinician called and spoke with an ophthalmologist (Dr. Daniels) and documented this discussion of management. This would meet the criteria for Moderate, Level 4 in this category.

Risk of Complications and/or Morbidity or Mortality of Patient Management

An urgent referral was documented for an evaluation by an ophthalmologist.  This would meet the criteria for Moderate, Level 4 in this category.

2 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 Problems Addressed category and exceeded in the Risk category, 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:

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