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AMA approves E&M documentation changes

The AMA CPT Editorial Panel has approved revised guidelines for new and established office or outpatient visit codes 99202-99215 that woul...

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)

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