Coding Challenge: Sexually Transmitted Infections in Urgent Care

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.

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
Codes
Level 2:
Straightforward
Minor/self-limitedMinimal/noneMinimal risk99202
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
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

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

For an in-depth review of this topic, access the full course.

Interested in more Urgent Care content?

Submit your email below to get a free issue and to take advantage of free practice-improving updates for general urgent care practices, tips for reading EKGs, and treating lacerations!
 

Leave a Reply

Your email address will not be published. Required fields are marked *

%d bloggers like this: