Coding Challenge: Skin and Soft-Tissue Infections 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 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


  • 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.


  • Cat bite to right hand
  • Early cellulitis right hand


  • 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?

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Last Updated on July 19, 2023

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