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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)  

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