CPT CODES The Evaluation and Management Services

Using code 99213, the typical time a physician spends with a patient face-to-face is _____________ minutes.

15 minutes

Using code 99202, the typical time a physician spends with a patient is _________ minutes

20 minutes

A new patient is seen in this office with complaints of a fever, chills, and difficulty breathing. The patient states that he has not been well for several weeks now and has progressively gotten weaker. He has not been able to work for the past week and before that was frequently absent from work over the course of 2 weeks. He is uncertain how long fever has been present but believes that it has been approximately 4 days. He does not have a thermometer at home and does not know what his temperature has been. He has been sleeping in a living room recliner because when he lies down, he has increased difficulty breathing. The detailed history and examination centered around the respiratory and cardiovascular systems. The upper respiratory findings included conjunctival injection, nasal discharge, and pharyngeal erythema. A rapid test pack was used to diagnose the viral infection. Chest X-ray showed patchy bilateral infiltrates. The physician diagnosed the patient with influenza A. The medical decision making complexity was low.

99203

A new patient is admitted to the observation unit of the local hospital after a 10-foot fall from a ladder. The patient struck his head on the side of the garage as he fell into a hedge that somewhat broke his fall. He has significant bruising on the left side of his body and complains of a 5/10 pain under his left arm. A series of x-rays has been ordered in addition to an MRI. The physician completed a comprehensive history and physical examination. It was decided to admit the patient to observation based on some evidence that he may have hit the left side of his head during the fall. The medical decision making is moderately complex. The patient was discharged the following day.

99219

An established patient is admitted to the hospital by his attending physician after a car accident in which the patient hit the steering wheel of the automobile with significant enough force to fold the wheel backward. The patient complains of significant pain in the right shoulder. After a detailed history and physical examination, the physician believed the patient may have sustained a right rotator cuff injury. The medical decision making was straightforward in complexity.

99221

A 2-year-old boy with bacterial pneumonia is hospitalized and has had 5 days of antiobiotic therapy. Today the child developed a fever of 101 ?F with a mild rash on his torso. In a subsequent hospital visit, the attending physician performed a problem-focused history and examination. The MDM complexity was low.

99231

The attending physician for an inpatient requests a subsequent consultation from another physician who earlier in the week had provided an initial inpatient consultation. The consultant provides a detailed interval history and examination. The medical decision making was of high complexity.

99233

A patient is sent to a general surgeon office by her family physician for an opinion and recommendation for surgical repair of a hernia. A brief problem-focused history of present illness and a problem-focused examination of the affected body Area and organ system are performed in the office. The MDM complexity was straightforward.

99241

A second opinion is requested by a 90-year-old patient whose ophthalmologist recently diagnosed the patient with bilateral senile cataracts. Her regular ophthalmologist has recommended surgical removal of the cataracts and implantation of lenses. The patient presents to the clinic stating that she is concerned about the necessity of the procedure at this time. During the detailed history, the patient states that she has had decreasing vision over the last year or two but has always had excellent vision. She cannot recall any eye trauma in the past. The physician conducted a detailed visual examination and confirmed the diagnosis of the patient's ophthalmologist. The medical decision making was of low complexity.

99243

A cardiology consultation is requested for a 71-year-old inpatient for recent onset of dyspnea on exertion and chest pain. The comprehensive history reveals that the patient cannot walk three blocks without exhibiting retrosternal squeezing sensation with shortness of breath. She relates that she had the first episode 3 months ago, which she attributed to indigestion. Her medical history is negative for stroke, tuberculosis, cancer, or rheumatic fever but includes seborrheic keratosis and benign positional vertigo. She has no known allergies. A comprehensive physical examination reveals a pleasant, elderly female in no apparent distress. She has a blood pressure of 150/70 with a heart rate of 76. Weight is 131 pounds, and she is 5 foot 4 inches. Head and neck reveals JBP less than 5 cm. Normal carotid volume and upstroke without bruit. Chest examination shows clear to auscultation with no rales, crackles, crepitations, or wheezing. Cardiovascular examination reveals a normal PMI without RV lift. Normal S1 and S2 with an S3, without murmur, are noted. The medical decision making complexity is high based on the various diagnosis options.

99255

The attending physician requests a consultation for an inpatient from an interventional radiologist for a second opinion about a 63-year-old male with abnormal areas within the liver. The recommendation for a CT-guided biopsy is requested, which the attending has recommended be performed. During the comprehensive history, the patient reported right upper quadrant pain. His liver enzymes were elevated. Previous CT study revealed multiple low attenuation areas within the liver (infection versus tumor). The laboratory studies were creatine, 0.9; hemoglobin, 9.5; PT and PTT, 13.0/31.5 with an INR of 1.2. The comprehensive physical examination showed that the lungs were clear to auscultation and the heart had regular rate and rhythm. The mental status was oriented times three. Temperature, intermittent low-grade fever, up to 101°F, usually occurred at night. The CT-guided biopsy was considered appropriate for this patient. The medical decision making was of high complexity.

99255

A new patient presents to the emergency department with an ankle sprain received when he fell while rollerblading. The patient is in apparent pain, and the ankle has begun to swell. He is unable to flex the ankle. The patient reports that he did strike his head on the sidewalk as a result of the fall. The physician completes an expanded problem focused history and examination. The medical decision making complexity is low.

99282

A 66-year-old male presents for a complete physical. There are no new complaints since my previous examination on 06/09 of last year. The patient spends 6 hours a week golfing and reports a brisk and active retirement. He does not smoke and has only an occasional glass of wine. He sleeps well but has been having nocturia times three. On physical examination, the patient is a well-developed, well-nourished male. The physician continues and provides a complete examination of the patient lasting 45 minutes.

99397

A 67 year-old female is admitted with severe exacerbation of her COPD. The patient is now in respiratory failure and CHF. The patient is intubated and unconscious; 155 minutes of critical care time was spent at bedside and coordinating care for this patient. (4 codes; separate each code with a comma and space)

99291, 99292, 99292, 99292

An 89-year-old female patient is admitted to the skilled nursing facility after being seen in the office earlier today. The daughter brought the patient to the office. As part of the detailed history, conducted with the patient's daughter, it is found that the patient was diagnosed with dementia last year. The patient was moved to this city from Anytown so that the daughter could care for her mother. The patient is noncontributory, and the physician relies on the medical record documentation brought in by the daughter from her mother's previous physician. Of late, the patient has become more and more withdrawn and noncommunicative. She has wandered away from the daughter's home twice last week and on the last occasion was found walking on the street. After a comprehensive examination, it was decided that the patient would be admitted to the nursing facility today. The physician spent 45 minutes with the patient and in preparation of the medical documentation for admittance to the nursing facility. The medical decision making was of high complexity.

99306

An established patient is seen in a nursing facility by the physician because the patient, who is a diabetic, has developed a Stage II decubitus ulcer with cellulites. The physician performs a detailed history and examination. The medical decision making complexity is moderate. The physician revises the patient's medical care plan.

99309

The physician provides a service to a new patient in a custodial care center. The patient is a paraplegic who has pneumonia of moderate severity. The physician performed an expanded problem-focused history and examination. The examination focused on the respiratory and cardiovascular systems, based on the patient's current complaint and past history of tachycardia. The medical decision making was of low complexity.

99325

The physician provides services to a new patient who is in a custodial care center. The patient is a 43 year-old paraplegic who has severe infected stasis ulcers. The physician performs a detailed history and examination and prescribes an antibiotic. The MDM was straightforward.

99326

Using code 99215, the physician spends a total of 1 ½ hours with the patient in his office. What prolonged service codes should be used in addition to the primary code?

99354

Sally Smith, an established patient, came into the office for his yearly physical examination. Sally is 71 and in good health.

99397