Initial consultation is performed for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed. 99205- The patient is a new patient who needs a comprehensive amount of data. The patient has unexplained symptoms, so it is very important to get the history in order to help figure out what may be causing these symptoms. A 30-year-old established patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge.
A detailed examination reveals bronchitis and sinus infection. The patient is prescribed a 5-day course of Zithromax. 99214- The patient is an established patient who is experiencing flu-like symptoms. The patient must have a detailed examination in order to figure out what the diagnosis is, it could be a multiple amount of different things. The risk was moderate because the patient was prescribed medication for 5 days and sent home. Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function.
A nurse briefly reviews the results and advises the patient that tests are normal, and no change in dosage is indicated. 99211- The patient is an established patient and is returning to do routine blood work. The patient probably is required to provide the minimal amount of data. Since the patient has come in to only check on the therapeutic levels and kidney functions and to do blood work it is minimal. A 62-year-old diabetic female presents to her primary care physician for a bandage change of a wound on her left foot.
A problem-focused examination reveals the wound is healing. The nurse applies a new dressing and patient will return for a check-up in one week. 99212- The patient is an established patient and this code was chosen because it was a problem-focused examination, but straightforward. The patient had a minimal amount of risk due to the fact that she has diabetes and it is important to heal any wounds that may be on your feet. You can lose your foot if the wound is not treated. A mother brings in her 6-month-old male child for his first routine wellness check.
A problem-focused history and examination reveals the child to be in good health and making adequate progress. 99215- The patient is an established patient because the child is 6 months old and has probably been seen before. The visit was comprehensive and the medical decision was of high complexity. This was decided because of the child’s medical history. Reference: The McGraw-Hill Companies, (2008). Procedural Coding: Introduction to CPT, p. 161-165. Retrieved July 17, 2010 from University of Phoenix.