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.

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

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:

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