Coding Challenge: Tick-Borne Illness in Urgent Care

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


35-year-old male established patient presents to urgent care with a chief complaint of a rash to the arms and legs. He noticed the rash 4 days ago; it started on his hands and feet and has progressed to his upper arms and upper legs. He returned from a camping trip to North Carolina 4 days ago. Associated symptoms include a low-grade fever, fatigue, muscle aches, and a bad headache. He has taken OTC ibuprofen for the muscle aches and headache, and says it does lessen the headache for a couple of hours. He has used hydrocortisone with no improvement. No CP, SOB, dizziness, abdominal pain, or GI complaints.

Past Medical History

  • None

Current Medications

  • OTC ibuprofen

Drug Allergies

  • NKDA


  • BP: 144/88 mm HG
  • HR: 104 Reg
  • RR: 16
  • Temp: 100.9°F
  • SPO2: 97%
  • Height: 5’9”
  • Weight: 168 lbs.
  • A&OX3: sitting on exam table, no acute distress.
  • HEENT: PERRLA, no corneal injection. Oropharynx clear, no erythema or exudates. TMs clear without erythema.  
  • Neck: No adenopathy or JVD
  • Lungs: CTAB, no rales, rhonchi, or wheezing
  • Heart: Regular rate without murmur
  • Abdomen: BS X 4, no guarding, rigidity, or rebound tenderness Skin: There is a blanching erythematous macular rash on the extremities.  No vesicles, bulla, pustules, or abscesses.


  • Fever
  • Headache
  • Suspect Rocky Mountain spotted fever


  • You discuss the patient’s management with an infectious disease specialist (external provider). The specialist instructs you to start doxycycline 100 mg BID for 14 days. She will see the patient in her office tomorrow at 8 a.m.
  • Doxycycline 100 mg BID X 14 days
  • OTC ibuprofen for fever, headache, and muscle aches
  • Patient understands and agrees with the plan. He will go to the ED for any worsening of his condition.

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Your email address will not be published.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 *