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Tag Archives: Clinical

Clinical Examples for 99291

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First hour of critical care of a 65-year-old man with septic shock following relief of ureteral obstruction caused by a stone.

First hour of critical care a 15-year-old with acute respiratory failure from asthma

First hour of critical of a 45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile.

First hour of critical care of a 65-year-old women who, following a hysterectomy, suffered a cardiac arrest associated with a pulmonary embolus.

First hour of critical care of a 6-month-old with hypovolemic shock secondary to diarrhea and dehydration

First hour critical of a 3-year-old with respiratory failure secondary to pneumocystis carinii pneumonia


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Clinical Examples for 99282

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Emergency department visit for a 20-year-old student who presents with a painful sunburn with blister formation on the back.  

Emergency department visit for a child presenting with impetigo localized to the face.  

Emergency department visit for a patient with a minor traumatic injury of an extremity with localized pain, swelling, and bruising.  

Emergency department visit for an otherwise healthy patient whose chief complaint is red, swollen cystic lesion on his/her back.  

Emergency department visit for a patient presenting with a rash on both legs after exposure to poison ivy. 

Emergency department visit for a young adult patient with infected sclera and purulent discharge from both eyes without pain, visual disturbance, or history of foreign body in either eye.  


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Clinical Examples for 99283

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Emergency department visit for a sexually active female complaining of vaginal discharge who is afebrile and denies experiencing abdominal or back pain.  

Emergency department visit for a well-appearing 8-year-old who has a fever, diarrhea, and abdominal cramps; is tolerating oral fluids and is not vomiting. 

Emergency department visit for a patient with an inversion ankle injury, who is unable to bear weight on the injured foot and ankle. 

Emergency department visit for a patient who has a complaint of acute pain associated with a suspected foreign body in the painful eye.  

Emergency department visit for a healthy for a healthy, young adult patient who sustained a blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness, or memory deficit. 


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Clinical Examples for 99284

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Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.  

Emergency department visit for an elderly female who has fallen and is now complaining of pain in her right hip and is unable to walk. 

Emergency department visit for a patient with flank pain and hematuria. 

Emergency department visit for a female presenting with lower abdominal pain and a vaginal discharge. 


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Clinical Examples for 99285

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Emergency department visit for a patient with a complicated overdoes requiring aggressive management to prevent side effects from the ingested materials.  

Emergency department visit for a patient with a new onset of rapid heart rate requiring IV drugs. 

Emergency department visit for a patient exhibiting active, upper gastrointestinal bleeding.

Emergency department visit for a previously healthy young adult patient who is injured in an automobile accident and is brought to the emergency department immobilized and has symptom compatible with intra-abdominal injuries or multiple extremity injuries. 

Emergency department visit for a patient with an acute onset of chest pain compatible with symptoms of cardiac ischemia and/or pulmonary embolus. 

Emergency department visit for a patient who presents with a sudden onset of ‘’the worst headache or her life,” and complains of a stiff neck, nausea, and inability to concentrate.  

Emergency department visit for a patient with a new onset of a cerebral vascular accident.  

Emergency department visit for acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness.  


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Clinical Examples for 99255

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Initial inpatient consultation for a 76-year-old female with massive, life-treatening gastrointestinal hemorrhage and chest pain. (Gastroenterology)

Initial inpatient consultation for a 75-year-old female, admitted to intensive care with acute respiratory distress syndrome, who is hypersensitive, and has a moderate metabolic acidosis, and a rising serum creatinine. (Nephrology)

Initial hospital consultation for patient with a history of complicated low back pain and neck problems with previous multiple failed back surgeries. (Orthopaedic surgery/Neurosurgery)

Initial hospital consultation for a 66-year-old female, two days post-abdominal aneurysm repair, with oliguria and hypertension of one-day duration. (Nephrology/Internal Medicine)

Initial hospital consultation for a patient with shotgun wound to face with massive facial trauma and airway obstruction. (Oral & Maxillofacial Surgery)

Initial hospital consultation for patient with server pancreatitis complicated by respiratory insufficiency, acute renal failure, and abscess formation. (General Surgery/Colon & Rectal Surgery)

Initial hospital consultation for a 35—year-old multiple-trauma male patient with complex pelvic fractures to evaluate and formulate management plan. (Orthopedic Surgery)

Initial inpatient consultation for adolescent patient with fractured femur and pelvis who pulled out IVs and disconnected traction in attempt to elope from hospital. (Psychiatry)

Initial hospital consultation for a 16-year-old primigravida at 32-weeks gestation requested by a family practitioner for evaluation of severe hypertension, thrombocytopenia, and headache. (Obstetrics & Gynecology)

Initial hospital consultation for 58-year-old insulin-dependent diabetic with multiple antibiotic allergies, now with multiple fascial plane plane abscesses and airway obstruction. (Oral & Maxillofacial Surgery)

Initial inpatient consultation for a 55-year-old male with known cirrhosis and ascites, now with jaundice, encephalopathy, and massive hematemesis. (Gastroenterology)

Initial hospital consultation for a 25-year-old male, seen in emergency room with server, closed head injury. (Neurosurgery)

Initial hospital consultation for a 2-day male with single ventricle physiology and subaortic obstruction, Family counseling following evaluation for multiple, staged surgical procedures. (Thoracic Surgery)

Initial hospital consultation for a 45-year-old male admitted with subarachnoid hemorrhage and intracranial aneurysm on angiogram. (Neurosurgery)

Initial inpatient consultation for myxedematous patient who is hypoventilating and obtunded. (Endocrinology)

Initial hospital consultation for a 45-year-old patient with widely metastatic lung carcinoma, intractable back pain, and a history that includes substance dependence, NSAID allergy, and two prior laminectomies with fusion for low back pain. (Pain Medicine)

Initial hospital consultation for evaluation of treatment options in a 50-year-old patient with cirrhosis, known peptic ulcer disease, hypotension, encephalopathy, and massive acute upper gastrointestinal bleeding that cannot be localized by endoscopy. (Interventional Radiology)

Initial inpatient consultation in the ICU for a 70-year-old male who experienced a cardiac arrest during surgery and was resuscitated. (Cardiology)

Initial inpatient consultation for a patient with severe pancreatitis complicated by respiratory insufficiency, acute renal failure, and abscess formation. (Gastroenterology)

Initial inpatient consultation for a 70-year-old cirrhotic male admitted with ascites, jaundice, encephalopathy, and massive hematemesis. (Gastroenterology)

Initial inpatient consultation in the ICU for a 51-year-old patient who is an a ventilator and has a fever two weeks after a renal transplantation. (Infectious Disease)

Initial inpatient consultation for evaluation and formulation of plan for management of multiple-trauma patient with complex pelvic fracture, 35-year-old male, (General Surgery/Orthopaedic Surgery)

Initial inpatient consultation for a 50-year-old male with a history of previous myocardial infarction, now with acute pulmonary edema and hypotension. (Cardiology)

Initial inpatient consultation for 45-year-old male with recent, acute subarachnoid hemorrhage, hesitant speech, mildly confused, drowsy, High risk group for HIV+ status. (Neurosurgery)

Initial inpatient consultation for 36-year-old female referred by her internist to evaluate a patient being followed for abdominal pain and fever, The patient has developed diffuse abdominal pain, guarding, rigidity, and increased fever. (Obstetrics & Gynecology)


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Clinical Examples for 99203

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Initial office visit of a 76-years-old male with a stasis ulcer of three months’ duration.  (Dermatology)

Initial office visit for a 30-years-old female with pain in the lateral aspect of the forearm.  (Physical Medicine & Rehabilitation)

Initial office visit for a 15-years-old patient with a four-year history of moderate comedopapular acne of the face, chest, and back with early scarring, Discussion of use of systemic medication.  (Dermatology)

Initial office visit for a patient with papulosquamous eruption of the elbow with pitting of nails and itchy scalp.  (Dermatology)

Initial office visit for a 57-years-old female who complains of painful period swelling of one week’s duration.  (Oral & Maxillofacial Surgery)

Initial office visit for a patient with an ulcerated non-healing lesion or nodule on the tip of the nose.  (Dermatology)

Initial office visit for a patient with dermatitis of the antecubital and popliteal fossae. (Dermatology)

Initial office visit for a 22-years-old female with irregular menses. (Family Medicine)

Initial office visit for a 50-years-old female with dyspepsia and nausea. (Family Medicine)

Initial office visit for a 53-years-old laborer with degenerative joint disease of the knee with no prior treatment  (Orthopaedic Surgery)

Initial office visit for a 60-years0old male with Dupuytren’s contracture of one hand with multiple digit involvement. (Orthopaedic Surgery)

Initial office visit for a 33-years-old male with painless gross hematuria without cystoscopy. (Internal Medicine)

Initial office visit for a 55-years-old female with chronic blepharitis, There is a history of use of many medicines. (Ophthalmology)

Initial office visit for an 18-years-old female with a two-day history of acute conjunctivitis, Extensive history of possible exposures, prior normal ocular history, and medication use is obtained.  (Ophthalmology) 

Initial office visit for a 14-years-old male with unilateral anterior knee pain. (Physical Medicine & Rehabilitation)      

Initial office visit of an adult who presents with symptoms of an upper-respiratory infection that has progressed to unilateral purulent nasal discharge and discomfort in the right maxillary teeth. (Otolaryngology/head & Neck Surgery)

Initial office visit of a 40-years-old female with symptoms of atopic allergies including eye and sinus congestion, often associated with infections. She would like to be tested for allergies.  (Otolaryngology/Head & neck Surgery)

Initial office visit of a 65-years-old with nasal stuffiness. (Otolarygology/Head & Neck Surgery)

Initial office visit for initial evaluation of a 48-years-old man with recurrent low back pain radiating to the leg. (General Surgery)

Initial office visit for evaluation, diagnosis, and management of painless hematuria in a new patient, without cystoscopy. (Internal Medicine)

Initial office visit with couple for counseling concerning voluntary vasectomy for sterility, Spent 30 minutes discussing procedure, risks and benefits, and answering questions. (Urology)

Initial office visit of a 49-years-old male with nasal obstruction, Detailed exam with topical anesthesia. (Plastic Surgery)

Initial office visit for evaluation of a 13-years-old female with progressive scoliosis. (Physical Medicine & Rehabilitation)

Initial office visit for a 21-years-old female desiring counseling and evaluation of initiation of contraception. (Family Practice/Internal Medicine/Obstetrics & Gynecology)

Initial office visit for a 49-years-old male presenting with painless blood per rectum associated with bowel movement. (Colon & Rectal Surgery)

Initial office visit for a 19-years-old football player with three-day-old acute knee injury; now with swelling and pain. (Orthopaedic Surgery) 


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Clinical Examples for 99204

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Initial office visit for a 13-years-old female with progressive scoliosis. (Orthopaedic Surgery)

Initial office visit for a 34-years-old female with primary infertility for evaluation and counseling. (Obstetrics & Gynecology)

Initial office visit for a 6-years-old male with multiple upper respiratory infections. (Allergy & Immunology)

Initial office visit for a patient with generalized dermatitis of 80 percent of the body surface area. (Dermatology)

Initial office visit for an adolescent who was referred by school counselor because of repeated skipping school. (Psychiatry)

Initial office visit for a 50-years-old machinist with a generalized eruption. (Dermatology)

Initial office visit for a 45-years-old female who has been abstinent form alcohol and benzodiazepines for three months but complains of headaches, insomnia, and anxiety. (Psychiatry)

Initial office visit for a 60-years-old male with recent change in bowel habits, weight loss, and abdominal pain. (Abdominal Surgery/General Surgery)

Initial office visit for a 50-years-old male with in aortic aneurysm who is considering surgery. (General Surgery)

Initial office visit for a 17-years-old female with depression. (Internal Medicine)

Initial office visit of a 40-years-old with chronic draining ear, imbalance, and probable cholesteatoma. (Otolaryngology/Head & Neck Surgery)

Initial office visit for initial evaluation of a 63-years-old male with chest pain on exertion. (Cardiology/Internal Medicine)

Initial office visit for evaluation of a 70-years-old patient with recent onset of episodic confusion. (Internal Medicine)

Initial office visit for a 7-years-old female with juvenile diabetes mellitus, new to area, past history of hospitalization times three. (Pediatrics)

Initial office visit of a 50-years-old female with progressive solid food dysphagia. (Gastroenterology)

Initial office visit for a 34-years-old patient with primary infertility, including counseling. (Obstetrics & Gynecology)

Initial office visit for evaluation of a 70-years-old female with polyarthralgia. (Rheumatology)

Initial office visit for a patient with papulosquamous eruption involving 60 percent of the cutaneous surface with joint pain, Combination of topical and systemic treatment discussed. (Dermatology)


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Clinical Examples for 99205

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Initial office visit for a patient with disseminated lupus erythematosus with kidney disease, edema, purpura, and scarring lesions on the extremities plus cardiac symptoms. (Dermatology/General Surgery/Internal Medicine)

Initial office visit for a 25-years-old female with systemic lupus erythematosus, fever, seizures, and profound thrombocytopenia. (Rheumatology/Allergy & Immunology) 

Initial office visit for an adult with multiple cutaneous blisters, denuded secondarily infected ulcerations, oral lesions, weight loss, and increasing weakness refractory to high does corticosteroid. Initiation of new immunosuppressive therapy. (Dermatology)

Initial office visit for a 28-years-old male with systemic vasculitis and compromised circulation to the limbs. (Rheumatology)

Initial office visit for a 41-years-old female new to the area requesting rheumatologic care, no disability due to scleroderma and recent hospitalization for malignant hypertension. (Rheumatology)

Initial office visit for a 52-years-old female with acute four extremity weakness and shortness of breath one weak post-fly vaccination. (Physical Medicine & Rehabilitation)

Initial office visit for a 60-years-old male previous back surgery; now presents with back and pelvic pain, two-month history of bilateral progressive calf and thigh tightness and weakness when walking, causing several falls. (Orthopaedic Surgery)

Initial office visit for an adolescent referred from emergency room after making suicide gesture. (Psychiatry)

Initial Office visit for a 49-years-old female with a history of headaches and dependence on opioids, She reports weight loss, progressive headache, and depression. (Psychiatry)

Initial office visit for a 50-years-old female with symptoms of rash, swelling, recurrent arthritic complaints, and diarrhea and lymphadenopathy, Patient has had a 25 lb weight loss and was recently camping in the Amazon. (Allergy & Immunology)

Initial office visit for a 34-years-old uremic Type I diabetic patient referred for ESRD modality assessment and planning. (Nephrology)

Initial office visit for a 75-years-old female with neck and bilateral shoulder pain, brisk deep tendon reflexes, and stress incontinence. (Physical Medicine & Rehabilitation)

Initial office visit for an 8-years-old male with cerebral palsy and spastic quadriparesis. (Physical Medicine & Rehabilitation)         

Initial office visit for a 73-years-old male with known prostate malignancy, who presents with sever back pain and a recent onset of lower extremity weakness. (Physical Medicine & Rehabilitation)

Initial office visit for a 38-years-old male with paranoid delusions and a history of alcohol abuse. (Psychiatry)

Initial office visit for a 12-weak-old with bilateral hip dislocations and bilateral club feet. (Orthopaedic Surgery)

Initial office visit for a 29-years-old female with acute orbital congestion, eyelid retraction, and bilateral visual loss from optic neuropathy. (Ophthalmology)

Initial office visit for a 70-years-old diabetic patient with progressive visual field loss, advanced optic disc cupping, and neovascularization of retina. (Ophthalmology)

Initial office visit for a newly diagnosed Type I diabetic patient. (Endocrinology)

Initial office evaluation of a 65-years-old female with exertional chest pain, intermittent claudication, syncope, and a murmur of aortic stenosis. (Cardiology)

Initial office visit for a 73-years-old male with an unexplained 20 lb weight loss. (Hematology/Oncology)

Initial office evaluation, patient with systemic lupus erythematosus, fever, seizures, and profound thrombodytopenia. (Allergy & Immunology/Internal Medicine/Rheumatology)

Initial office evaluation and management of patient with systemic vasculitis and compromised circulation to the limbs. (Rheumatology)

Initial office visit for a 24-year-old homosexual male who has a fever, a cough, and shortness of breath. (Infection Disease)

Initial outpatient evaluation of a 69-years-old male with sever chronic obstructive pulmonary disease, congestive heart failure, and hypertension. (family Medicine)

Initial office visit for a 17-years-old female, who is having school problems and has told a friend that she is considering suicide, The patient and her family are consulted in regard to treatment options. (Psychiatry)         
Initial office visit for a female with severe hirsutism, amenorrhea, weight loss, and a desire to have children. (Endocrinology/Obstetrics & Gynecology)       

Initial office visit for a 42-year-old male on hypertensive medication, newly arrived to the area, with diastolic blood pressure of 110, history of recurrent calculi, episodic headaches, intermittent chest pain, and orthopnea. (Internal Medicine)


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