Here is an example of a coded report for CPT code 99283, which is used for emergency department visits that require a moderately complex medical decision-making:
Patient Encounter Information
- Date of service: April 8, 2023
- Chief complaint: Severe abdominal pain
- History of present illness: The patient, a 45-year-old male, presents to the emergency department with severe abdominal pain that started approximately 6 hours ago. The pain is located in the lower abdomen and is constant. The patient reports nausea and vomiting and has not been able to tolerate any oral intake. He denies any recent trauma, fever, or diarrhea.
Physical Exam Findings
- General: The patient appears uncomfortable and is lying still on the stretcher. He is alert and oriented to person, place, and time.
- Vital signs: Blood pressure 140/90 mmHg, heart rate 110 beats per minute, respiratory rate 20 breaths per minute, temperature 37.2 degrees Celsius, and oxygen saturation 98% on room air.
- Abdomen: The abdomen is distended and tender to palpation in the lower quadrants. There is no guarding or rebound tenderness. Bowel sounds are hypoactive.
Assessment and Plan
Based on the patient’s history, physical exam, and initial laboratory results, the working diagnosis is acute appendicitis. The patient will be started on intravenous fluids and pain medication. Blood will be drawn for complete blood count and basic metabolic panel. A surgical consultation will be requested for evaluation and possible appendectomy.
CPT Code 99283
The patient’s presenting symptoms and physical exam findings support a moderately complex medical decision-making. The medical decision-making includes consideration of the patient’s history, physical exam, and initial laboratory tests. Therefore, the appropriate CPT code for this visit is 99283.
Note: This is a general example and the documentation and coding requirements may vary based on individual case scenarios and medical necessity. It is important to review the CPT coding guidelines and documentation requirements to ensure accurate coding and billing.