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Tag Archives: examples

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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Clinical Examples for 99211

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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)


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Clinical Examples for 99212

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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)


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Clinical Examples for 99213

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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

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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