Here’s an example of a coded report for CPT code 99282:
Date of Service: 04/10/2023
Patient: John Smith
Procedure: Emergency department visit, moderate severity (99282)
Chief Complaint:
The patient presented to the emergency department with complaints of severe abdominal pain and nausea for the past 24 hours. He also reported a fever of 101°F and chills.
History of Present Illness:
John Smith is a 42-year-old male who reports a 24-hour history of severe abdominal pain and nausea. He describes the pain as a constant, dull ache in the mid-epigastric region, radiating to the back. The pain is exacerbated by eating and is associated with vomiting. He also reports a fever of 101°F and chills. The patient denies any recent travel or sick contacts.
Past Medical History:
The patient has a history of hypertension, but otherwise has no significant past medical history.
Physical Examination:
Vital signs on admission were: blood pressure 140/90 mmHg, heart rate 105 bpm, respiratory rate 20 breaths/min, temperature 101.2°F, and oxygen saturation 97% on room air. Examination of the abdomen revealed tenderness and guarding in the epigastric region. There was no rebound tenderness or hepatosplenomegaly. Bowel sounds were hypoactive.
Assessment and Plan:
The patient’s clinical presentation is consistent with acute pancreatitis. A complete blood count, comprehensive metabolic panel, and lipase level were ordered. The patient was started on intravenous fluids, pain management, and antiemetics. The patient was admitted to the hospital for further management and observation.
CPT code 99282 is appropriate for this visit, as the patient presented to the emergency department with moderate severity abdominal pain, required a detailed history and examination, and required medical decision-making of moderate complexity.