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Clinical Examples for 99211


Office visit for an 82-year-old female, established patient for a monthly B12 injection with documented Vitamin B12 deficiency. (Geriatrics/Internal Medicine/Family Medicine)

Office visit for a 50-year-old male, established patient, for removal of uncomplicated facial sutures. (Plastic Surgery)

Office visit for an established patient who lost prescription for lichen planus, Returned for new copy. (Dermatology)

Office visit for an established patient undergoing orthodontics who complains of a wire that is irritating his/her cheek and asks you to check it. (Oral & Maxillofacial Surgery)

Office visit for a 50-year-old female, established patient, seen for her gold injection by the nurse. (Rheumatology)

Office visit for a 73-year-old female, established patient, with pernicious anemia for weekly B12 injection. (Gastroenterology)

Office visit for an established patient for dressing change on a skin biopsy. (Dermatology)

Office visit for a 19-year-old female, established patient, for removal of sutures from a 2 cm laceration of forehead, which you placed four days ago in ER. (Plastic Surgery)

Office visit of a 20-year-old female, established patient, who receives an allergy vaccine injection and is observed for a reaction by the nurse. (Otolaryngology/Head & Neck Surgery)

Office visit for a 45-year-old male, established patient, with chronic renal failure for the administration of erythropoietin. (Nephrology)

Office visit for an established patient, a Peace Corps enlistee, who requests documentation that third molars have been removed. (Oral & Maxillofacial Surgery)

Office visit for a 69-year-old female, established patient, for partial removal of antibiotic gauze from an infected wound site. (Plastic Surgery)

Office visit for a 9-year-old, established patient, successfully treated for impetigo, release to return to school. (Dermatology/Pediatrics)

Office visit for an established patient requesting a return-to-weak certificate for resolving contact dermatitis. (Dermatology)

Office visit for an established patient who is performing glucose monitoring and wants to check accuracy of machine with lab blood glucose by technician who checks accuracy and function of patient machine. (Endocrinology)

Follow-up office visit for a 65-year-old female with a chronic indwelling percutaneous nephrostomy catheter seen for routine pericatheter skin care and dressing change. (Interventional Radiology)

Outpatient visit with 19-year-old male, established patient, for supervised drug screen. (Addiction Medicine)

Office visit with 12-year-old male, established patient, for cursory check of hematoma one day after venipuncture. (Internal Medicine)

Office visit with 31-year-old female, established patient, for return to work certificate. (Anesthesiology)

Office visit for a 42-year-old, established patient, to read tuberculin test results. (Allergy & Immunology)

Office visit for 14-year-old, established patient, to re-dress an abrasion. (Orthopaedic Surgery)

Office visit for a 45-year-old female, established patient, for a blood pressure check. (Obstetrics & Gynecology)

Office visit for a 23-year-old, established patient, for instruction in use of peak flow meter. (Allergy & Immunology)

Office visit for prescription refill for a 35-year-old female, established patient, with schizophrenia who is stable but has run out of neuroleptic and is scheduled to be seen in a week. (Psychiatry)


Coding Ahead

Clinical Examples for 99212


Office visit for an 11-year-old, established patient, seen in follow-up for mild comedonal acne of the cheeks on topical desquamating agents. (Dermatology/Family Medicine/Pediatrics)

Office visit for a 10-year-old female, established patient, who has been swimming in a lake, now presents with a one-day history of left ear pain with purulent drainage.(Family Medicine)

Office visit for a child, established patient, with chronic secretory otitis media. (Otolaryngology/Head & Neck Surgery)

Office visit for an established patient seen in follow-up of clearing patch of localized contact dermatitis. (Family Medicine/Dermatology)

Office visit for an established patient returning for evaluation of response to treatment of lichen planus on wrists and ankles. (Dermatology)

Office visit for an established patient with tinea pedis being treated with topical therapy. (Dermatology)

Office visit for an established patient with localized erythematous plaque of psoriasis with topical hydration. (Dermatology)

Office visit for a 50-year-old male, established patient, recently seen for acute neck pain, diagnosis of spondylosis, responding to physical therapy and intermittent cervical traction. Returns for evaluation for return to work. (Neurology)

Office visit for an established patient with recurring episodes of herpes simplex who has developed a clustering of vesicles on the upper lip. (Oral & Maxillofacial Surgery)

Evaluation of a 50-year-old male, established patient, who has experienced a recurrence of knee pain after he discontinued NSAID. (Anesthesiology/Pain Medicine)

Office visit for an established patient with an irritated skin tag for reassurance. (Dermatology)

Office visit for a 40-year-old, established patient, who has experienced a systemic allergic reaction following administration of immunotherapy, The dose must be readjusted. (Allergy & Immunology)

Office visit for a 33-year-old, established patient, for contusion and abrasion of lower extremity. (Orthopaedic Surgery)

Office visit for a 22 –year-old male, established patient, one month after I & D of “wrestler’s ear”. (Plastic Surgery)

Office visit for a 21-year-old, established patient, who is seen in follow-up after antibiotic therapy for acute bacterial tonsillitis. (Otolarygology/Head & Neck Surgery)

Office visit for a 4-year-old, established patient, with tympanostomy tubes, check-up. (Otolarynology/Head & Neck Surgery)

Office visit for an established patient who has had needle aspiration of a peritonsillar abscess. (Orolaryngology/Head & Neck Surgery)

Follow-up office examination for evaluation and treatment of acute draining ear in a 5-year-old with tympanotomy tubes. (Otolaryngology/Head & Neck Surgery)

Office visit, established patient, 6-year-old with sore thorat and headache. (Family Medicine/Pediatrics)

Office evaluation for possible purulent bacterial conjunctivitis with one-to two-day history of redness and discharge, 16-year-old female, established patient. (Pediatrics/Internal Medicine/Family Medicine)

Office visit for a 65-year-old female, established patient, returns for three-week follow-up for resolving severe ankle sprain. (Orthopaedic Surgery)

Office visit, sore throat, fever, and fatigue in a 19-year-old college student, established patient. (Internal Medicine)

Office visit with a 33-year-old female, established patient, recently started on treatment for hemorrhoidal complaints, for re-evaluation. (Colon & Rectal Surgery)

Office visit for a 27-year-old female, established patient, with complaints of vaginal itching. (Obstetrics & Gynecology)

Office visit for a 65-year-old, established patient, with eruptions on both arms from poison oak exposure. (Allergy & Immunology/Internal Medicine)


Coding Ahead

Clinical Examples for 99213


Office visit for an established patient with new lesions of lichen planus in spite of topical therapies. (Dermatology)

Office visit for the quarterly follow-up of a 45-year-old lame with stable chronic asthma requiring regular drug therapy. (Allergy & Immunology)

Office visit for a 13-year-old, established patient, with comedopapular acne of the face that has shown poor response to topical medication, Discussion of use of systemic medication. (Dermatology)

Office visit for a 62-year-old female, established patient, for follow-up for stable cirrhosis of the liver. (internal Medicine/Family Medicine)

Office visit for a 3-year-old, established patient, with atopic dermatitis and food hypersensitivity for quarterly follow-up evaluation ,The patient is on topical lotions and steroid creams as well as oral antihistamines. (Allergy & Immunology)

Office visit for an 80-year-old female, established patient, to evaluate medical management of osteoarthritis of the temporomandibular joint. (Rheumatology)

Office visit for a 70-year-old female, established patient, one year post excision of basal cell carcinoma of nose with nasolabial flap, Now presents with new suspicious recurrent lesion and suspicious lesion of the back. (Plastic Surgery)

Office visit for a 68-year-old female, established patient, with polymyalgia rheumatic, maintained on chronic low-does corticosteroid, with no new complaints.(Rheumatology)

Office visit for a 3-year-old female, established patient, for earache and dyshidrosis of feet. (Pediatrics/Family Medicine)

Office visit for an established patient for 18-months post-operative follow-up of TMG repair. (Oral & Maxillofacial Surgery)

Office visit for a 45-year-old male, established patient, being re-evaluated for  recurrent acute prostatitis. (Urology)

Office visit for a 43-year-old male, established patient, with known reflex sympathetic dystrophy. (Anesthesiology)

Office visit for an established patient with an evenly pigmented superficial nodule of leg that is symptomatic. (Dermatology)

Office visit for an established patient with psoriasis involvement of the elbows, pitting of the nails, and itchy scalp. (Dermatology)

Office visit for a 27-year-old male, established patient, with deep follicular and perifollicular inflammation unable to tolerate systemic antibiotics due to GI upset, requires change of systemic medication. (Dermatology)

Office visit for a 16-year-old male, established patient, who is on medication for exercise-induced bronchospasm. (Allergy & Immunology)

Office visit for a 60-year-old, established patient, with chronic essential hypertension on multiple drug regimen, for blood pressure check. (Family Medicine)

Office visit for a 20-year-old male, established patient, for removal of sutures in hand. (Family Medicine)

Office visit for a 58-year-old female, established patient, with unilateral painful bunion. (Orthopaedic Surgery)

Office visit for a 45-year-old female, established patient, with known osteoarthritis and painful swollen knees. (Rheumatology)

Office visit for a 25-year-old female, established patient, complaining of bleeding and heavy menses. (Obstetrics & Gynecology)

Office visit for a 55-year-old male, established patient, with hypertension managed by a beta blocker/thiazide regime;  now experiencing mild fatigue. (Nephrology)

Office visit for a 65-year-old female, established patient, with primary glaucoma for interval determination of intraocular pressure and possible adjustment of medication. (Ophthalmology)

Office visit for a 56-year-old man, established patient, with stable exertional angina who complains of new onset of calf pain while walking. (Cardiology)

Office visit for a 63-year-old female, established patient, with rheumatoid arthritis on auranofin and ibuprofen, seen for routine follow-up visit. (Rheumatology)

Office visit for an established patient with Graves’s disease, three months post I-131 therapy, who presents with lassitude and malaise.(Endocrinology)

Office visit for the quarterly follow-up of a 63-year-old male, established patient, with chronic myofascial pain syndrome, effectively managed by doxepin, who presents with new onset urinary hesitancy. (Pain Medicine)

Office visit for the biannual follow-up of an established patient with migraine variant having infrequent, intermittent, moderate to severe headache with nausea and vomiting, which are sometimes effectively managed by ergotamine tartrate and an antiemetic, but occasionally requiring visits to an emergency department. (Pain Medicine)

Office visit for an established patient after discharge from a pain rehabilitation program to review and adjust medication dosage. (Pain Medicine)

Office visit with 55-year-old male, established patient, for management of hypertention, mild fatigue, on beta blocker/thiazide regimen. (Family Medicine/Internal Medicine)

Outpatient visit with 37-year-old male, established patient, who is three years post total colectomy for chronic ulcerative colitis, presents for increased irritation at his stoma. (General Surgery)

Office visit for a 70-year-old diabetic hypertensive established patient with recent change in insulin requirement. (Internal Medicine/Nephrology)

Office visit with 80-year-old female, established patient, for follow-up osteoporosis, status-post compression fractures. (Rheumatology)

Office visit for an established patient with stable cirrhosis of the liver. (Gastroenterology)

Routine, follow-up office evaluation at a three-month interval for a 77-year-old female, established patient, with nodular small cleaved-cell lymphoma. (Hematology/Oncology)

Quarterly follow-up office visit for a 45-year-old male, established patient, with stable chronic asthma, on steroid and bronchodilator therapy. (Pulmonary Medicine)

Office visit for a 50-year-old female, established patient, with insulin-dependent diabetes mellitus and stable coronary artery disease, for monitoring. (Family Medicine/Internal Medicine)


Coding Ahead

Clinical Examples for 99215


Office visit for an established patient who developed persistent cough, rectal bleeding, weekness, and diarrhea plus pustular infection on skin. Patient on immunosuppressive therapy. (Dermatology)

Office visit for an established patient with disseminated lupus erythematosus, extensive edema of extremities kidney disease, and weakness requiring monitored course on azathioprene, corticosteroid and complicated by acute depression. (Dermatology/Internal Medicine/Rheumatology)

Office visit for an establihed patient with progressive dermatomyositis and recent onset of fever, nasal speech, and requrgitation of fluids through the nose. (Dermatology)

Office visit for a 28-year-old female, established patient, who is abstinent from previous cocaine dependence but reports progressive panic attacks and chest pains. (Psychatry)

Office visit for an established adolescent patient with history of bipolar disorder treated with lithium; seen on urgent basis at family’s request because of server depressive symptoms. (Psychiatry)

Office visit for an established patient having acute migraine with new onset neurological symptoms and whose headaches are unresponsive to previous attempts at management with a combination of preventive and abortive medication. (Pain Medicine)

Office visit for an established patient with exfoliative lichen planus with daily fever spikes, disorientation, and shortness of breath. (Dermatology)

Office visit for a 25-year-old, established patient, two years post-burn with bilateral ectropion, hypertrophic facial bourn scars, near absence of left breast, and burn syndactyly of both hands, Discussion of treatment options following examination. (Plastic Surgery)

Office visit for a 6-year-old, established patient, to review newly diagnosed immune deficiency with recommendation for therapy including IV immunoglobulin and chronic antibiotics. (Allergy & Immunology)         

Office visit for a 36-year-old, established patient, three-month status post-transplant, with new onset of peripheral edema, increased blood pressure, and progressive fatigue. (Nephrology)

Office visit for an established patient with kaposi’s sarcoma who presents with fever and widespread vesicles. (Dermatology)

Office visit for a 27-year-old female, established patient, with bipolar disorder who was stable on lithium carbonate and monthly supportive psychotherapy but now has developed symptoms of hypomania. (Psychiatry)

Office visit for a 25-year-old male, established patient with a history of schizophrenia who has been seen bi-monthly but is complaining of auditory hallucinations. (Psychiatry)

Office visit for a 62-year-old male, established patient, three years postoperative abdominal perineal resection, now with a rising carcinoembryonic antigen, weight loss, and pelvic pain. (Abdominal Surgery)  

Office visit for an 42-year-old male, established patient, nine months postoperative emergency vena cava shunt for varicealbleeding, now present with complaints of one episode of “dark” bowel movement, weight gain, tightness in abdomen, whites of eyes seem yellow and occasional drowsiness after eating hamburgers. (Abdominal Surgery)

Office visit for a 68-year-old male, established patient, with biopsy-proven rectal carcinoma, for evaluation and discussion of treatment options. (General Surgery)

Office visit for a 60-year-old, established patient, with diabetic nephropathy with increasing edema and dyspnea. (Endocrinology)       

Office visit with 30-year-old male, established patient for three-month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. (Family Medicine)

Office visit for restaging of an established patient with new lymphadenopathy one year post-therapy for lymphoma. (Hematology/Oncology)

Office visit for evaluation of recent onset syncopal attacks in a 70-year-old female, established patient. (Internal Medicine)

Follow-up visit, 40-year-old mother of three, established patient, with acute rheumatoid arthritis, anatomical Stage 3, ARA function. (Rheumatology)

Follow-up office visit for a 65-year-old male, established patient, with a fever or recent onset while on outpatient antibiotic therapy for endocarditis. (Infectious Disease)

Office visit for a 75-year-old, established patient, with ALS (amyotrophic lateral sclerosis), who is not longer able to swallow. (Neurology)

Office visit for a 70-year-old female, established patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation, and short-term memory loss. (Family Medicine/Internal Medicine)  


Coding Ahead

Clinical Examples for 99231


Subsequent hospital visit for a 65-year-old female, post-open reduction and internal fixation of a fracture. (Physical medicine & Rehabilitation)

Subsequent hospital visit for a 33-year-old patient with pelvis pain who is responding to pain medication and observation. (Obstetrics & Gynecology)

Subsequent hospital visit for a 21-year-old female with hyperemesis who has responded well to intravenous fluids. (Obstetrics & gynecology)

Subsequent hospital visit to re-evaluate postoperative pain and titrate patient-controlled analgesia for a 27-year-old female. (Anesthesiology)

Follow-up hospital visit for a 35-year-old female, status post-epidural analgesia. (Anesthesiology/Pain Medicine)                           

Subsequent hospital visit for a 56-year-old male, post-gastrectomy, for maintenance of analgesia using an intravenous dilaudid infusion. (Anesthesiology)

Subsequent hospital visit for a 4-year-old on day three receiving medication for uncomplicated pneumonia. (Allergy & Immunology)

Subsequent hospital visit for a 30-year-old female with urticaria that has stabilized with medication (Allergy & Immunology)

Subsequent hospital visit for a 76-year-old male with venous stasis ulcers. (Dermatology)

Subsequent hospital visit for a 24-year-old female with otitits externa, seen two days before in consultation, now to have otic wick removal. (Otolaryngology/Head &Neck Surgery)

Subsequent hospital visit for a 27-year-old with acute labyrinthitis. (Otolaryngology/Head & Neck surgery)

Subsequent hospital visit for a 10-year-old male admitted for lobar pneumonia with vomiting and dehydration; is becoming afebrile and tolerating oral fluids. Family Medicine/Pediatrics)

Subsequent hospital visit for a 62-year-old patient with resolving cellulitis of the foot. (Orthopaedic Surgery)

Subsequent hospital visit for a 25-year-old male admitted for supra-ventricular tachycardia and converted on medical therapy. (Cardiology)

Subsequent hospital visit for a 27-year-old male two days after open reduction aand internal fixation for malar complex fracture. (Plastic Surgery)

Subsequent hospital visit for a 76-year-old male with venous stasis ulcers. (Geriatrics)

Subsequent hospital visit for a 67-year-old female admitted three days ago with bleeding gastric ulcer; now stable. (Gastroenterology)

Subsequent hospital visit for a stable 33-year-old male, status post-lower gastrointestinal bleeding. (General Surgery/Gastroenterology)

Subsequent hospital visit for a 29-year-old auto mechanic with effort thrombosis of left upper extremity. (General Surgery)

Subsequent hospital visit for a 14-year-old female in middle phase of inpatient treatment, who is now behaviorally stable and making satisfactory progress in treatment. (Psychiatry)

Subsequent hospital visit for an 18-year-old male with uncomplicated asthma who is clinically stable. (Allergy & Immunology)

Subsequent hospital visit for a 55-year-old male with rheumatoid arthritis, two days following an uncomplicated total joint replacement. (Rheumatology)

Subsequent hospital visit for a 60-year-old dialysis patient with an access infection, now afebrile on antibiotic. (Nephrology)

Subsequent hospital visit for a 36-year-old female with stable post-rhinoplasty epistaxis. (Plastic Surgery)

Subsequent hospital visit for a 66-year-old female with L-2 vertebral compression fracture with resolving ileus. (Orthopaedic Surgery)

Subsequent hospital visit for a patient with peritonsillar abscess. (Otolaryngology/Head & Neck Surgery)

Subsequent hospital visit for an 18-year-old female responding to intravenous antibiotic therapy for ear or sinus infection. (Otolaryngology/Head & Neck Surgery)

Subsequent hospital visit for a 70-year-old male admitted with congestive heart failure who has responded to therapy. (Cardiology)

Follow-up hospital visit for a 32-year-old female with left ureteral calculus; being followed in anticipation of spontaneous passage. (Urology)

Subsequent hospital visit for a 4-year-old female, admitted for acute gastroenteritis and dehydration, requiring lV hydration; now stable. (Family Medicine)

Subsequent hospital visit for a 50-year-old Type ll diabetic who is clinically stable and without complications requiring regulation of a single does of insulin daily. (Endocrinology)

Subsequent hospital visit to reassesses the status of 65-year-old patient post-open reduction and internal fixation of hip fracture, on the rehab unit. (Physical Medicine & Rehabilitation)

Subsequent hospital visit for a 78-year-old male with cholangiocarcinoma managed by biliary drainage. (Interventional Radiology)

Subsequent hospital visit for a 50-year-old male with uncomplicated myocardial infarction who is clinically stable and without chest pain. (Family Medicine/Cardiology/Internal Medicine)

Subsequent hospital visit for a stable 72-year-old lung cancer patient undergoing a five-day course of infusion chemotherapy. (Hematology/Oncology)

Subsequent hospital visit, two days post admission for a 65-year-old male with a CVA (cerenral vascular accident) and left hemiparesis, who is clinically stable. (Neurology/Physical Medicine & Rehabilitation)

Subsequent hospital visit for now stable, 33-year-old male, status post lower gastrointestinal bleeding. (Genera Surgery)

Subsequent visit on third day of hospitalization for a 60-year-old female recovering from an uncomplicated pneumonia. (Infectious Disease/Internal Medicine/Pulmonary Medicine)

Subsequent hospital visit for a 3-year-old patient in traction for a congenital dislocation of the hip. (Orthopaedic Surgery)

Subsequent hospital visit for a 4-year-old female, admitted for acute gastroenteritis and dehydration, requiring lV hydration; now stable. (Family Medicine/Internal Medicine)

Subsequent hospital visit for 50-year-old female with resolving uncomplicated acute pancreatitis. (Gastroenterology)


Coding Ahead

Clinical Examples for 99232


Subsequent hospital visit for a patient with venous stasis ulcers who developed fever and red streaks adjacent to the ulcer. (Dermatology/Internal Medicine/Family Medicine)

Subsequent hospital visit for a 66-year-old male for dressing changes and observation, Patient has had a myocutaneous flap to close a pharyngeal fistula and now has a low-grade fever. (Plastic Surgery)

Subsequent hospital visit for a 54-year-old female admitted for myocardial infarction, but who is now having frequent premature ventricular contractions. (Internal Medicine) 

Subsequent hospital visit for an 80-year-old patient with a pelvic rim fracture, inability to walk, and severe pain, now 36-hours post-injury, experiencing urinary retention. (Orthopaedic Surgery)                   

Subsequent hospital visit for a 17-year-old female with fever, pharyngitis, and airway obstruction, who after 48 hours develops a maculopapular rash. (Pediatrics/Family Medicine)

Follow-up hospital visit for a 32-year-old patient admitted the previous day for corneal ulcer. (Dermatology)

Follow-up visit for a 67-year-old male with congestive heart failure who has responded to antibiotics and diuretics and has now developed a monoarthropathy. (Internal Medicine)

Follow-up hospital visit for a 58-year-old male receiving continuous opioids who is experiencing severe nausea and vomiting. (Pain Medicine)

Subsequent hospital visit for a patient after an auto accident who is slow to respond to ambulation training. (Physical Medicine & Rehabilitation)

Subsequent hospital visit for a 14-year-old with unstable bronchial asthma complicated by pneumonia. (Allergy & Immunology)

Subsequent hospital visit for a 50-year-old diabetic, hypertensive male with back pain not responding to conservative inpatient management with continued radiation of pain to the lower left extremity. (Orthopaedic Surgery)

Subsequent hospital visit for a 37-year-old female on day five of antibiotics for bacterial endocarditis, who still has low-grade fever. (Cardiology)

Subsequent hospital visit for a 54-year-old patient, post Ml (myocardial infarction), who is out of the CCU (coronary care unit) but is now having frequent premature ventricular contractions on telemetry. (Cardiology/Internal Medicine)

Subsequent hospital visit for a patient with neutropenia, a fever responding to antibiotics, and continued slow gastrointestinal bleeding on platelet support. (Hematology/Oncology)

Subsequent hospital visit for a 50-year-old male admitted two days ago for sub-acute renal allograft rejection. (Nephrology)

Subsequent hospital visit for a 35-year-old drug addict, not responding to initial antibiotic therapy for pyelonephritis. (Urology)

Subsequent hospital visit of an 81-year-old male with abdominal distention, nausea, and vomiting. (General Surgery)

Subsequent hospital care for a 62-year-old female with congestive heart failure, who remains dyspneic and febrile. (Internal Medicine)

Subsequent hospital visit for a 73-year-old female with recently diagnosed lung cancer, who complains of unsteady gait. (Pulmonary Medicine)

Subsequent hospital visit for a 20-month-old male with bacterial meningitis treated one week with antibiotic therapy; has now developed a temperature of 101 degrees. (Pediatrics)

Subsequent hospital visit for 13-year-old male admitted with left lower quadrant abdominal pain and fever, not responding to therapy. (General Surgery)

Subsequent hospital visit for a 65-year-old male with hemiplegia and painful paretic shoulder. (Physical Medicine &Rehabilitation)


Coding Ahead

Clinical Examples for 99233


Subsequent hospital visit for a 38-year-old male, quadriplegic with acute autonomic hyperreflexia, who is not responsive to initial care. (Physical Medicine & Rehabilitation)

Follow-up hospital visit for a teenage female who continues to experience severely disruptive, violent, and life-threatening symptoms in a complicated multi-system illness, Family/social circumstances also a contributing factor. (Psychiatry)

Subsequent hospital visit for a 42-year-old female with progressive systemic sclerosis (scleroderma), renal failure on dialysis, congestive heart failure, cardiac arrhythmias, and digital ulcer. (Allergy & Immunology)

Subsequent hospital visit for a 50-year-old diabetic, hypertensive male with non responding back pain and radiating pain to the lower left extremity, who develops chest pain, cough, and bloody sputum. (Orthopaedic Surgery)

Subsequent hospital visit for a 64-year-old female, status post-abdominal aortic aneurysm resection, with non-responsive coagulopathy, who has now developed lower Gl bleeding. (Abdominal Surgery/Colon & Rectal Surgery/General Surgery)

Follow-up hospital care of patient with pansinusitis infection complicated by a brain abscess and asthma; no response to current treatment. (Otolaryngology/Head & Neck Surgery)

Subsequent hospital visit for a patient with a laryngeal neoplasm who develops airway compromise, suspected metastasis. (Otolaryngology/Head & Neck Surgery)

Subsequent hospital visit for a 49-year-old male with significant rectal bleeding, etiology undetermined, not responding to treatment. (Abdominal Surgery/General Surgery/Colon & Rectal Surgery)

Subsequent hospital visit for a 50-year-old male, post-aortocoronary bypass surgery; now develops hypotension and oliguria. (Cardiology)

Subsequent hospital visit for an adolescent patient who is violent, unsafe, and noncompliant, who multiple expectations for participation in treatment plan and behavior on the treatment unit. (Psychiatry)

Subsequent hospital visit for an 18-year-old male being treatment for presumed PCP psychosis, Patient is still moderately symptomatic with auditory hallucinations and is insisting on signing out against medical advice. (Psychiatry)

Subsequent hospital visit for an 8-year-old female with caustic ingestion, who now has fever, dyspnea, and dropping hemoglobin. (Gastroenterology)

Follow-up hospital visit for a chronic renal failure patient on dialysis who develops chest pain and shortness of breath and a new onset pericardial friction rub. (Nephrology)

Subsequent hospital visit for a 44-year-old patient with electrical burns the left arm with ascending infection. (Orthopaedic Surgery)

Subsequent hospital visit for a patient with systemic sclerosis who has aspirated and is short of breath. (Dermatology)

Subsequent hospital visit for a 65-year-old female, status postoperative resection of abdominal aortic aneurysm, with suspected ischemic bowel. (General Surgery)

Subsequent hospital visit for a 50-year-old male, post-aortocoronary bypass Surgery, now develops hypotension and oliguria. (Cardiology)

Subsequent hospital visit for a 50-year-old male, following an acute myocardial infarction, who complains of shortness of breath and new chest pain. (Cardiology)

Subsequent hospital visit for a 65-year-old female with rheumatoid arthritis (stage 3, class 3) admitted for urosepsis, On the third hospital day, chest pain, dyspnea, and fever develop. (Rheumatology)

Follow-up hospital care of pediatric case with stridor, laryngomalacia, established tracheostomy, complicated by multiple medical problems in PICU. (Otolarygology/Head & Neck Surgery)

Subsequent hospital visit for a 60-year-old female, four days post uncomplicated inferior myocardial infraction who has developed severe chest pain, dyspnea, diaphoresis, and nausea. (Family Medicine)

Subsequent hospital visit for a patient with AMLL (acute myelogenous leukemia), fever, elevated white count and uric acid undergoing induction chemotherapy. (Hematology/Oncology)

Subsequent hospital visit for a 38-year-old quadriplegic male with acute autonomic hyperreflexia, who is not responsive to initial care. (Physical Medicine & Rehabilitation)

Subsequent hospital visit for a 65-year-old female postoperative resection of abdominal aortic aneurysm, with suspected ischemic bowel. (General Surgery)

Subsequent hospital visit for a 60-year-old female with persistent leukocytosis and a fever seven day after a sigmoid colon resection for carcinoma. (Infectious Disease)

Subsequent hospital visit for a chronic renal failure patient on dialysis, who develops chest pain, shortness of breath, and new onset pericardial friction rub. (Nephrology)

Subsequent hospital visit for a 65-year-old male with acute myocardial infraction who now demonstrates complete heart block and congestive heart failure. (Cardiology)

Subsequent hospital visit for a 25-year-old female with hypertension an systemic lupus erythematosus, admitted for fever and respiratory distress, On the third hospital day, the patient presented with purpuric skin lesions and acute renal failure. (Allergy & Immunology)

Subsequent hospital visit for a 55-year-old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acute respiratory distress requiring ventilator support in the ICU. The patient was stabilized, extubated, and transferred to the floor but has now developed acute fever, dyspnea, left lower lobe rhonchi, and laboratory evidence of carbon dioxide retention and hypoxemia. (Family Medicine/Internal Medicine)

Subsequent hospital visit for 46-year-old female, known liver cirrhosis patient, with recent upper gastrointestinal hemorrhage from varices; now with worsening ascites and encephalopathy. (Gastroenterology)

Subsequent hospital visit for 62-year-old female admitted with acute subarachnoid hemorrhage, hegative cerebral arteriogram, increased lethargy, and hemiparesis with fever. (Neurosurgery)


Coding Ahead

Clinical Examples for 99241


Initial office consultation for a 40-year-old female in pain from blister on lip following a cold. (Oral & Maxillofacial Surgery)

Initial office consultation for a 62-year-old construction worker with olecranon bursitis. (Orthopaedic Surgery)

Office consultation with 25-year-old postpartum female with sever symptomatic hemorrhoids. (Colon & Rectal Surgery)

Office consultation with 58-year-old male, referred for follow-up of creatinine level and evaluation of obstr5uctive uropathy, relieved two months ago. (Nephrology)

Office consultation for 30-year-old female tennis player with sprain or contusion of the forearm. (Orthopaedic Surgery)

Office consultation for a 45-year-old male, requested by his internist, with asymptomatic torus palatines requiring no further treatment. (Oral & Maxillofacial Surgery)


Coding Ahead

Clinical Examples for 99242


Initial office consultation for a 20-year-old male with acute upper respiratory tract symptoms. (Allergy & Immunology)

Initial office consultation for a 29-year-old soccer player with painful proximal thigh/groin injury. (Orthopaedic Surgery)

Initial office consultation for a 66-year-old female with wrist and hand pain, numbness of finger tips, suspected median nerve compression by carpal tunnel syndrome. (Plastic Surgery)

Initial office consultation for a patient with a solitary lesion of discoid lupus erythmatosus on left cheek to rule out malignancy or self-induced lesion. (Dermatology)

Office consultation for management of systolic hypertension in a 70-year-old male scheduled for elective prostate resection. (Geriatrics)

Office consultation with 27-year-old female, with old amputation, for evaluation of existing above-knee prosthesis. (Physical Medicine & Rehabilitation)

Office consultation with 66-year-old female with wrist and hand pain, and finger numbness, secondary to suspected carpal tunnel syndrome. (Orthopaedic Surgery)

Office consultation for 61-year-old female, recently on antibiotic therapy, now with diarrhea and leukocytosis. (Abdominal Surgery)

Office consultation for a patient with papulosquamous eruption of elbow with pitting of nails and itchy scalp. (Dermatology)  

Office consultation for a 30-year-old female with single season allergic rhinitis. (Allergy & Immunology)


Coding Ahead

Clinical Examples for 99243


Initial office consultation for a 60-year-old male with avascular necrosis of the left femoral head with increasing pain. (Orthopaedic Surgery)

Office consultation for a 31-year-old women complaining of palpitations and chest pain, Her internist had describe a mild systolic click. (Cardiology)

Office consultation for a 65-year-old female with persistent bronchitis. (Infectious Disease)

Office consultation for a 65-year-old man with chronic low-back pain radiating to the leg. (Neurosurgery)

Office consultation for 23-year-old female with Crohn’s disease not responding to therapy. (Abdominal Surgery/Colon & Rectal Surgery)

Office consultation for a25-year-old patient with symptomatic knee pain and swelling, with torn anterior cruciate ligament and/or torn meniscus. (Orthopaedic Surgery)

Office consultation for a 67-year-old patient with osteoporosis and mandibular atrophy with regard to reconstructive alternatives. (Oral & maxillofacial Surgery)

Office consultation for 39-year-old patient referred at a perimenopausal age for irregular menses and menopausal symptoms. (Obstetrics & Gynecology)


Coding Ahead