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

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
Level 2:
Minor/self-limitedMinimal/noneMinimal risk99202
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
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
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
• Significant social
determinants of health
Level 5: High• Severe illness with
• 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
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

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:

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Last Updated on July 19, 2023

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