A patient presents to an urgent care facility with a complaint of a sore throat and fever. A strep test is administered, and the results are positive. The patient is diagnosed with strep throat and is prescribed antibiotics. When considering the level of medical decision making (MDM) for the visit, should all urgent care complaints be considered “moderate” for the level of decision-making category given that the complaints can be considered an “undiagnosed new problem with uncertain prognosis” and that the prescription of medication can be considered “prescription drug management”? ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium article explains how to think about medical decision making in an urgent care setting when a patient presents with a common infectious complaint and receives testing and treatment. It is aimed at coders, auditors, and billing staff who need a better understanding of how visit complexity is assessed and why certain assumptions about MDM level do not always hold. The article discusses broad MDM concepts, the role of diagnosis status, and medication-related considerations without turning every urgent care encounter into the same level of service.

Why This Topic Matters

Urgent care encounters are often coded under time pressure, and misunderstandings about MDM can lead to inconsistent level selection. This article helps readers understand the broader evaluation framework so they can apply documentation-based judgment rather than relying on shortcuts.

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