Determine the correct evaluation and management (E/M) service code for this urgent care encounter:
SUBJECTIVE
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
OBJECTIVE
- 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.
ASSESSMENT
- Fever
- Headache
- Suspect Rocky Mountain spotted fever
PLAN
- 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?
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
This male patient complains of rash, muscle aches, headache, and fatigue. His temperature is 100.9°F with a heart rate of 104 beats/min. This meets the criteria for SIRS (Systemic Inflammatory Response Syndrome) and thus, would be an acute illness with systemic symptoms, which is Moderate, Level 4 in the category of Problems Addressed.
Amount and/or Complexity of Data to be Reviewed and Analyzed
No lab tests were ordered or reviewed, and no independent historian was documented. Discussion of management with the infectious disease specialist (external provider) was documented. This would meet the criteria for Moderate, Level 4 in the category of Complexity of Data.
Risk of Complications and/or Morbidity or Mortality of Patient Management
The patient was prescribed doxycycline, which meets the criteria for Moderate, Level 4 in the category of Risk.
2 of the 3 Elements of Medical Decision Making must be met or exceeded when choosing the level of service. Level 4 criteria were met in the Problems Addressed, Complexity of Data, and Risk categories, so the correct E/M code is 99204.
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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