Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
Presentation
24-year-old female presents to the clinic with chief complaints of lower abdominal pain, vaginal discharge, and dysuria. She states her symptoms started 4 days ago and are progressively worsening. Two weeks ago, her boyfriend broke up with her, but a week ago, they had sexual intercourse. She has never had an STI in the past. She has taken OTC Tylenol® for the abdominal pain but it did not help. LMC 3 weeks ago and no abnormalities.
Past Medical History
None
Current Medications
OTC acetaminophen PRN
Drug Allergies
- Bactrim — rash
- Biaxin — rash
OBJECTIVE
BP: 124/78
HR: 88 Reg
RR: 14
SPO2: 98%
Ht.: 5’6”
Wt.: 145 lbs.
A&OX3, NAD, VSS, no apparent distress
HEENT: PERRLA, no corneal injection.
Oropharynx: no erythema or exudates
Neck: no adenopathy
Lungs: CTAB, no rales, rhonchi, or wheezing
Heart: RRR without murmur
Abdomen: mild TTP suprapubic region, BSX4, no G/R/R
Pelvic exam: thin yellowish discharge, no vaginal bleeding visualized, +CMT and a friable cervix, no lesions or foreign objects, no perineal rash or lesions.
Recent results
- Urine pregnancy test is negative.
- UA shows leukocytes and trace blood.
ASSESSMENT
- Abdominal pain – suprapubic
- Vaginal discharge
- Dysuria
PLAN
Orders Placed in the Encounter
- Urinalysis
- Urine pregnancy test
- Urine culture
- NuSwab® vaginal swab (tests for gonorrhea, chlamydia, trichomonas, bacterial vaginosis, and vaginal yeast infection)
Facility-Administered Encounter Medications
Rocephin 500 mg IM
Medications Prescribed During the Encounter
Doxycycline 100 mg BID X 7 days
Patient was offered blood work to check for other STIs (hepatitis B/C, HIV, and syphilis) but she refused. She states she will follow up with her PCP for further testing.
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
This female patient complains of lower abdominal pain, vaginal discharge, and dysuria. At discharge, we did not have a definitive diagnosis. This meets the definition for “1 undiagnosed new problem”1 with uncertain prognosis, which meets the criteria for Moderate, Level 4 in this category.
Amount and/or Complexity of Data to be Reviewed and Analyzed
A POC urinalysis and urine pregnancy test were performed. A urine culture and a NuSwab® VG were sent to the laboratory for further testing. It is also important to note the patient was offered blood work to test for other STIs, but she refused additional testing at this time. This will add to the complexity of data. Four labs were ordered, so this meets the criteria for Moderate, Level 4 in this category.
Risk of Complications and/or Morbidity or Mortality of Patient Management
A Rocephin® injection was given in the clinic and a prescription for doxycycline was sent to the pharmacy. This meets the criteria for Moderate, Level 4 in this category.
2 of the 3 Elements of Medical Decision Making must be met when choosing the level of service. This encounter met Level 4 criteria in all 3 of the categories, 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
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