Coding Challenge: Sexually Transmitted Infections in Urgent Care

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


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


Current Medications

OTC acetaminophen PRN

Drug Allergies

  • Bactrim — rash
  • Biaxin — rash


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.


  • Abdominal pain – suprapubic
  • Vaginal discharge
  • Dysuria


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?

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Your email address will not be published.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 *