Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
SUBJECTIVE
34-year-old female, new patient, presents to your urgent care with a chief complaint of a cat bite to her right hand. She states her hand is red and painful. The incident occurred about 16 hours ago while she was playing with her cat. She cleaned the area with soap and water and took ibuprofen 400 mg, which helps for about an hour or 2. Pain is of moderate severity. Other associated symptoms have included pain with any movement of her right hand. She denies fever, or numbness/tingling to her hand.
Current Medications
- OTC ibuprofen
Drug Allergies
- NKDA
OBJECTIVE
- Temp 99.5 °F (37.5 °C) (Tympanic)
- BP 127/87 mm Hg
- Pulse 71
- Resp 16
- SpO2 99%
- Ht 5′ 5″
- Wt 250 lb (113.4 kg)
- General appearance: Alert, cooperative and no distress, obese
- Head: Normocephalic
- Lungs: Clear to auscultation bilaterally
- Heart: Normal, regular rhythm, S1, S2 normal, no murmur, click, rub or gallop Right hand: There are 3 puncture wounds to the dorsum of her hand over the 4th and 5th metacarpals with 3 cm surrounding erythema. No drainage. Limited ROM of her 4th and 5th digits due to pain. Red streaking is also noted from the puncture wounds radiating to her wrist and distal forearm.
ASSESSMENT
- Cat bite to right hand
- Early cellulitis right hand
PLAN
- Discussed diagnosis with patient.
- Keep the area covered, clean, and dry.
- New medications: Augmentin 875 mg BID for 7 days. OTC NSAID PRN pain. Follow up in 3-5 days or sooner if symptoms do not improve. Go to ED if worse
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
The patient complaint is a cat bite to her right hand. This would fall under “1 acute, uncomplicated illness or injury”, which is a Low, Level 3, in this category.
Amount and/or Complexity of Data to be Reviewed and Analyzed
No lab tests were ordered, no external notes were reviewed, no independent historian, and no discussion of management of the patient were documented. This would meet the criteria for Straightforward, Level 2, in this category.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Augmentin was prescribed. This would meet the criteria for prescription drug management, which is 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 3 criteria were met in the Problems Addressed category and exceeded in the Risk category, so the correct E/M code is 99203.
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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Last Updated on July 19, 2023
