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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 99223


Initial hospital visit for a 45-year-old female, who has a history of rheumatic fever as a child and now has anemia, fever, and congestive heart failure. (Cardiology)

Initial hospital visit for a 50-year-old male with acute chest pain and diagnostic electrocardiographic changes of an acute anterior myocardial infarction. (Cardiology/Family Medicine/Internal medicine)

Initial hospital visit for a 75-year-old with progressive stridor and dysphagia with history of cancer of the larynx treated by radiation therapy in the past, Exam shows a large recurrent tumor of the glottis with a mass in the neck. (Otolaryngology/Head & Neck Surgery)

Initial hospital visit for a 70-year-old male admitted with chest pain, complete heat block, and congestive heart failure. (Cardiology)

Initial hospital visit for an 82-year-old male who presents with syncope, chest pain, and ventricular arrhythmias. (Cardiology)

Initial hospital visit for a 75-year-old male with history of arteriosclerotic coronary vascular disease, who is severely dehydrated, disoriented, and experiencing auditory hallucinations, (Psychiatry)

Initial hospital visit for a 70-year-old male with alcohol and sedative-hypnotic dependence, admitted by family for severe withdrawal, hypertension, and diabetes mellitus. (Psychiatry)

Initial hospital visit for a persistently suicidal latency-aged child whose parents have requested admission to provide safety during evaluation but are anxious about separation from her. (Psychiatry)

Initial psychiatric visit for an adolescent patient without previous psychiatric history, who was transferred from the medical ICU after a significant overdose. (Psychiatry)

Initial hospital visit for a 35-year-old female with severe systemic lupus erythematosus on corticosteroid and cyclophosphamide, with new onset of fever, chills, rash, and chest pain. (Rheumatology)

Initial hospital visit for a 52-year-old male with know rheumatic heart disease who presents with anasarca, hypertension, and history of alcohol abuse. (Cardiology)

Initial hospital visit for a 55-year-old female with a history of congenital heart disease; now presents with cyanosis. (Cardiology)

Initial hospital visit for a psychotic, hostile, violently combative adolescent, involuntarily committed, for seclusion and restraint in order to provide for safety on unit. (Psychiatry)

Initial hospital visit for a now subdued and sullen teenage male with six-month history of declining school performance, increasing self-endangerment, and resistance of parental expectation, Including running away past weekend after physical fight with father. (Psychiatry)

Initial partial hospital admission for a 17-year-old female with history of borderline mental retardation who has developed auditory hallucinations, Parents are know to abuse alcohol, and Child Protective Service is investigating allegations of sexual of abuse of a younger sibling. (Psychiatry)

Initial hospital visit of a 67-year-old male admitted with a large neck mass, dysphagia, and history of myocardial infarction three months before. (Otolaryngology/Head & Neck Surgery)

Initial hospital visit for a patient with suspected cerebrospinal fluid rhinorrhea that developed two weeks after head injury. (Otolaryngology/Head & Neck Surgery)

Initial hospital visit for a 25-year-old female with history of poly-substance abuse and psychiatric disorder, The patient appears to be psychotic with markedly elevated vital signs. (Psychiatry)

Initial hospital visit for a 70-year-old male with cutaneous Y-cell Iymphoma who has developed fever and lumphadenopathy. (Internal Medicine)

Initial hospital visit for a 62-year-old female with know coronary artery disease, for evaluation of increasing edema, dyspnea on exertion, confusion, and sudden onset of fever with productive cough. (Internal Medicine)

Initial hospital visit for a 3-year-old female with 36-hour history of sore throat and high fever; now with sudden onset of lethargy, irritability, photophobia, and nuchal rigidity. (Pediatrics)

Initial hospital visit for a 26-year-old female for evaluation of severe facial fractures (LeFort’s ll/lll) (Plastic Surgery)

Initial hospital visit for a 55-year-old female for bilateral mandibular fractures resulting in flail mandible and airway obstruction. (Plastic Surgery)

Initial hospital visit for a 71-year-old patient with a red painful eye four days following uncomplicated cataract surgery due to endophthalmitis. (Ophthalmology)

Initial hospital visit for a 45-year-old patient involved in a motor vehicle accident who suffered a perforating corneoscleral laceration with loss of vision. (Ophthalmology)

Initial hospital visit for a 58-year-old male who has Ludwig’s angina and progressive airway compromise. (Oral & Maxillofacial Surgery)

Initial hospital visit for a patient with generalized systemic sclerosis, receiving immunosuppressive therapy because of recent onset of cough, fever, and inability to swallow. (Dermatology)

Initial hospital visit for an 82-year-old male who present with syncope, chest pain, and ventricular arrhythmias. (Cardiology)

Initial hospital visit for a 62-year-old male with history of previous myocardial infarction, comes in with recurrent, sustained ventricular tachycardia. (Cardiology)

Initial hospital visit for a chronic dialysis patient with infected PTFE fistula, septicemia, and shock. (Nephrology)

Initial hospital visit for a 1-year-old male, victim of child abuse, with central nervous system depression, skull fracture, and retinal hemorrhage. (Family Medicine/Neurology)

Initial hospital visit for a 25-year-old female with recent C4-C5 quadriplegia, admitted for rehabilitation. (Physical Medicine & Rehabilitation)

Initial hospital visit for an 18-year-old male, post-traumatic brain injury with multiple impairment. (Physical Medicine & Rehabilitation)

Initial partial hospital admission for 16-year-old male, sullen and subdued, with six-month history of declining school performance, increasing self-endangerment, and resistance to parental expectations. (Psychiatry)

Initial hospital visit for a 16-year –old primigravida at 32-weeks gestation at 32-weeks gestation with severe hypertension (200/110), thrombocytopenia, and headache. (Obstetrics & Gynecology)

Initial hospital visit for a 49-year-old male with cirrhosis of liver with hematemesis, hepatic encephalopathy, and fever. ((gastroenterology)

Initial hospital visit for a 70-year-old male, with multiple organ system disease, admitted with history of being aneuric and septic for 24 hours prior to admission. (Urology)

Initial hospital visit for a 3-year-old female with 36 hour history of sore throat and high fever, now with sudden onset of lethargy, irritability, photophobia, and unchal rigidity. (Internal Medicine)

Initial hospital visit for a 78-year-old male, transfer from nursing home with dysuria and pyuria, increasing confusion, and high fever. (Internal Medicine)

Initial hospital visit for a 1-day-old male with cyanosis, respiratory distress, and tachypnea. (Cardiology)

Initial hospital visit for a 3-day-old female with recurrent tachycardia and syncope. (Cardiology)

Initial hospital visit for a thyrotoxic patient who presents with fever, atrial fibrillation, and delirium. (Endocrinology)

Initial hospital visit for a 50-year-old Type l diabetic who presents with diabetic ketoacidosis with fever and obtundation. (Endocrinology)

Initial hospital visit for a 40-year-old female with anatomical stage 3, ARA functional class 3 rheumatoid arthritis on methotrexate, corticosteroid, and nonsteroidal anti-inflammatory drugs, Patient presents with severe arthritis flare, new oral ulcers, abdominal pain, and leucopenia. (Rheumatology)

Initial hospital exam of a pediatric patient with high fever and proptosis. (Otolaryngology/Head & Neck Surgery)

Initial hospital visit for a 25-year-old patient admitted for the first time to the rehab unit, with recent C4-C5 quadriplegia. (Physical Medicine & Rehabilitation)

Hospital admission, examination, and initiation of treatment program for a previously unknown 58-year-old male who presents with acute chest pain. (Cardiology)

Hospital admission, examination, and initiation of induction chemotherapy for a 42-year-old patient with newly diagnosed acute myeolgenous leukemia. (Hematology/Oncology)

Hospital admission following a motor vehicle accident of a 22-year-old male fracture dislocation of C5-C6; neurologically intact. (Neurosurgery)

Hospital admission for a 78-year-old female with left lower lobe pneumonia and a history of coronary artery disease, congestive heart failure, osteoarthritis, and gout. (Family Medicine)

Hospital admission, examination, and initiation of treatment program for a 65-year-old immunosuppressed male with confusion, fever, and a headache, (Infectious Disease) 

Hospital admission for a 9-year-old with vomiting, dehydration, fever, tachypnea, and an admitting diagnosis of diabetic ketoacidosis. (Pediatrics)

Initial hospital visit for a 65-year-old male who presents with acute myocardial infarction, oliguria, hypotension, and altered state of consciousness. (Cardiology)

Initial hospital visit for a hostile/resistant adolescent patient who is severely depressed and involved in poly-substance abuse, Patient is experiencing significant conflict in his chaotic family situation and was suspended from school following an attack on teacher with a baseball bat. (Psychiatry)

Initial hospital visit for 89-year-old female with fulminant hepatic failure and encephalopathy. (Gastroenterology)

Initial hospital visit for a 42-year-old female with rapidly progressing scleroderma, malignant hypertension, digital infarcts, and oligurea. (Rheumatology) 

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