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.

CHALLENGE: What is the appropriate E/M code for this encounter?

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