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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 99222


Initial hospital visit for a 50-year-old patient with lower quadrant abdominal pain and increased temperature, but without septic picture. (General Surgery/Abdominal Surgery/Colon & Rectal Surgery)

Initial hospital visit for airway management, due to a benign laryngeal mass. (Otolaryngology/Head & Neck Surgery)

Initial hospital visit for a 66-year-old female with an L-2 vertebral compression fracture with acute onset of paralytic ileus; seen in the office two days previously. (Orthopaedic Surgery)

Initial hospital visit and evaluation of a 15-year-old male admitted with peritonsillar abscess or cellulitis requiring intravenous antibiotic therapy/ (Otolaryngology/Head & Neck Surgery)

Initial hospital visit for a 42-year-old male with vertebral compression fracture following a motor vehicle accident. (Orthopaedic Surgery)

Initial hospital visit for a patient with generalized atopic dermatitis and secondary infection. (Dermatology)

Initial hospital visit for a 3-year-old patient with high temperature, limp, and painful hip motion of 18 hours’ duration, (Pediatrics/Orthopaedic Surgery)

Initial hospital visit for a young adult, presenting with an acute asthma attack unresponsive to outpatient therapy. (Allergy & Immunology)

Initial hospital visit for an 18-year-old male who has suppurative sialadenitis and dehydration. (Oral & Maxillofacial Surgery)

Initial hospital visit for a 65-year-old female for acute onset of thrombotic cerebrovascular accident with contralateral paralysis and aphasia. (Neurology)

Initial hospital visit for a 50-year-old male chronic paraplegic patient with pain and spasm below the lesion. (Anesthesiology)

Partial hospital admission for an adolescent patient from chaotic blended family, transferred from inpatient setting, for continued treatment to control symptomatic expressions of hostility and depression. (Psychiatry)

Initial hospital visit for a 15-year-old male with acute status asthmaticus, unresponsive to outpatient therapy. (Internal Medicine)

Initial hospital visit for a 61-year-old male with history of previous myocardial infarction, who now complains of chest pain. (Internal Medicine)

Initial hospital visit of a 15-year-old on medications for a sore throat over the last two weeks, The sore throat has worsened and patient now has dysphagia, The exam shows large necrotic tonsils with an adequate airway and small palpable nodes. The Initial mono test was negative. (Otolaryngology/Head & Neck Surgery)

Initial hospital evaluation of a 23-year-old allergy patient admitted with eyelid edema and pain on fifth day of oral antibiotic therapy. (Otolaryngology/Head & Neck Surgery)

Hospital admission, young adult pain, failed previous therapy and now present in acute asthmatic attack. (Family Medicine/Allergy & Immunology)

Hospital admission of a 62-year-old smoker, established patient, with bronchitis in acute respiratory distress. (Internal Medicine/Pulmonary Medicine)

Hospital admission, examination, and initiation of a treatment program for a 65-year-old female with new onset of right-side paralysis and aphasia. (Neurology)

Hospital admission, examination, and initiation of treatment program for a 66-year-old chronic hemodialysis patient with fever and a new pulmonary infiltrate. (Nephrology)

Hospital admission for an 8-year-old febrile patient with chronic sinusitis and severe headache, unresponsive to oral antibiotics. (Allergy & Immunology)

Hospital admission for a 40-year-old male with sub maxillary cellulitis and trismus from infected lower moral. (Oral & Maxillofacial Surgery)

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