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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 99254


Initial in patient consultation for a 15-year-old patient with painless swelling of proximal humerus with lytic lesion by X-ray. (Orthopaedic Surgery)

Initial hospital consultation for evaluation of a 29-year-old female with a diffusely positive medical review of systems and history of multiple surgeries. (Psychiatry)

Initial hospital consultation for a 70-year-old diabetic female with gangrene of the foot. (Orthopaedic Surgery)

Initial inpatient consultation for a 47-year-old female with progressive pulmonary infiltrate, hypoxemia, and diminished urine output. (Anesthesiology)

Initial hospital consultation for a 13-month-old with spasmodic cough, respiratory distress, and fever. (Allergy & Immunology)

Initial consultation for a patient with failed total hip replacement with loosening and pain upon walking. (Orthopaedic Surgery)

Initial hospital consultation for a 62-year-old female with metastatic breast cancer to the femoral neck and thoracic vertebra. (Orthopaedic Surgery)

Initial hospital consultation for a 39-year-old female with nephrolithiasis requiring extensive opioid analgesics, whose vital signs are now elevated, She initially denied any drug use but today gives history of multiple substance abuse, including opioids and prior treatment for a personality disorder. (Psychiatry)

Initial hospital consultation for a 70-year-old female without previous psychiatric history, who is now experiencing nocturnal confusion and visual halluncinations following hip replacement surgery. (Psychiatry)

Initial inpatient consultation for evaluation of a 63-year-old in the ICU with diabetes and chronic renal failure who develops acute respiratory distress syndrome 36 hours after a mitral value replacement. (Anesthesiology)

Initial inpatient consultation for a 66-year-old female with enlarged supraclavicular lymph nodes, found on biopsy to be malignant. (Hematology/Oncology)

Initial inpatient consultation for a 43-year-old female for evaluation of sudden painful visual loss, optic neuritis, and episodic paresthesia. (Ophthalmology)

Initial inpatient consultation for evaluation of a 71-year-old male with hyponatremia (serum sodium 114) who was admitted to the hospital with pneumonia. (Nephrology)

Initial inpatient consultation for a 72-year-old male with emergency admission for possible bowel obstruction. (Internal Medicine/General Surgery)

Initial inpatient consultation for a 35-year-old female with fever, swollen joints, and rash of one-week duration. (Rheumatology)

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