A 21-year-old patient seen in follow-up for otitis media after 10 days of antibiotic treatment. No complaints. ENT clear. Resolved otitis media. MDM was stated as straightforward.
99212
A 49-year-old female had a knee replacement yesterday. Today, she suffers a cardiac arrest. Cardiologist responds and provides 1 hour 35 minutes of critical care, orders a chest x-ray, and provides ventilation management.
99291, 99292 × 1
Office visit for 24-year-old patient with acute bronchitis. Expanded problem-focused history and exam are performed. MDM was stated as low.
99213
Hospital admission on 01/01, subsequent visits on 01/02, with discharge on 01/03.
99221, 99231, 99238
A physician is called in as a consultant for an inpatient in the hospital, and a problem-focused history and exam are performed with straightforward medical decision-making.
99231
Patient in ED has critical care services provided for a total of 1 hour 45 minutes. What E/M code(s) would be assigned?
99291, 99292 × 2
Patient presents today to discuss her upcoming surgery with her PCP. On assessing her social situation, she is suffering significant knee pain, especially on walking small distances and getting up and down, and would benefit greatly from the knee replacement surgery scheduled for next week by her orthopedic surgeon. MDM was straightforward.
99212
Patient met in ER by his regular physician complaining of chest pain. After comprehensive history and exam and high MDM, the patient is admitted by his physician to rule out myocardial infarction. Assign the admit level for this encounter.
99223
A 10-year-old presents having fallen approximately 2 hours ago. Ice was applied, however, swelling and pain continues. ED physician performs ROS involving four systems. Patient lives at home and attends grade school in the area. Multiple systems are evaluated. Multiple x-rays are obtained as well as labs and independent evaluation of x-rays and discussion of case with another health care provider. The ED physician performs conscious moderate sedation for 30 minutes that is monitored and documented appropriately. The fracture is reduced and casted by the orthopedist. ED Physician prescribed Tylenol #3, which was given for pain. What are the appropriate E/M services for the ED physician for this encounter?
99284-25, 99156, 99157
Established patient seen for earache. History and exam are problem focused and MDM is low. Diagnosis of otitis media, right, is made.
99213
A new patient presents to the office for evaluation of coronary artery disease and asthma. Hx extended into the affected systems and other related systems. Past medical, family, and social history are taken. Exam is detailed. MDM is considered high. What E/M level would be assigned in this instance?
99205
Annual preventive medicine exam for a 38-year-old established male patient.
99395
Work disability evaluation performed by family physician. What E/M services would be appropriate?
99455
Discharge summary: Patient was admitted 1 week ago due to episodes of increased shortness of breath and weakness. At discharge, patient is stable, will continue his or her digoxin 125 mg daily and all other meds as prior to admission.
99238
Chronic care management for a 74-year-old patient with debilitating arthritis and CAD, 20 minutes of clinical staff time via phone during the calendar month directed by qualified health care professional.
99490
A 24-year-old female with vaginal bleeding following fall presents to physician’s office for initial visit. States she slipped and fell today and landed on her left side. Began having abdominal pain and vaginal bleeding. Denies vaginal discharge; menstrual cycle completed 7–10 days ago. ROS, five systems. SH/FH: noncontributory. Exam is performed of six systems, GU in detail, and MDM is moderate.
99204
An initial office visit of a 56-year-old female with multiple medical problems. History includes three HPI elements, PMH, two ROS, two exam elements. Patient complains of severe abdominal pain, and CT of abdomen/pelvis, lab, and chest x-ray are ordered and interpreted.
99204
Patient arrives for office visit for the first time in 4 years; has been out of the country until recently. A comprehensive reevaluation, comprehensive exam, and high MDM are performed.
99205
Patient referred here by PCP for possible foot fracture. Patient stepped on something and has had pain and swelling since. X-ray performed at PCP indicates possible fracture, fifth metatarsal. Patient examined, x-rays reviewed, and a definitive diagnosis of closed metatarsal fracture made. Closed treatment performed and patient told to return in 2 weeks for reevaluation. Expanded problem-focused history and exam and low MDM are performed.
99213-57, 28470
An established patient is seen in the office for suture removal from a laceration repaired by the same physician 7 days ago. Patient is seen by physician’s nurse only, and sutures are removed without difficulty.
99024
A new patient is seen in the office with chest pain. The physician performs a detailed history and exam. The decision is made to admit the patient to the hospital, where a comprehensive history and exam are performed with high medical decision making. What level admit would be assigned?
99223
Patient admitted to CCU for an acute MI. Admission included comprehensive history and exam and high MDM. Patient was seen for 2 subsequent days where an expanded problem-focused history and exam and moderate MDM were performed. Patient was discharged on day 4.
99223, 99232 × 2, 99238
A 16-year-old patient for initial visit, referred by physical therapist at school. Injured foot in track practice and has been complaining of right ankle pain for about a month. Detailed history, detailed exam, and low MDM were performed.
99203
Patient returns to clinic today. She has been doing ice treatments for her knee injury and taking ibuprofen as needed. Knee has improved significantly. No swelling, no tenderness. Will continue conservative measures as needed. MDM was documented as straightforward.
99212
