Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

PHYSICIAN USE OF NEW VISIT CODES 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services’ (HHS) 

programs as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management problems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’S Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIG’S Office of Investigations (01) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 

unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions, 

administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’S Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. 

Oei’s Atlanta Regional Office prepared this report under the direction of Jesse J. Flowers, 

Regional Inspector General and Christopher Koehler, Deputy Regional Inspector General. 

Principal OEI staff included: 

REGION HEADQUARTERS 

Joe Townsel, Project Leader Tom Noplock, Program Analyst 

Betty Apt, Team Leader Barbara Tedesco, Statistician 

Jackie Andrews, Program Analyst Stuart Wright, Program AnaZyst 

Tammy Bonney, R-ogram AnaZyst 

For additional copies of this report, call the Atlanta Regional OffIce at (404) 331-4108. 
, 

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

PHYSICIAN USE OF NEW VISIT CODES


fs SERVIC&$ 

~$h “t/* 

9 

$W JUNE GIBBS BROWN 

:

d Inspector General #

% %d~~ % $

$+2 MAY1995 

OEI-O4-92-O1O6O 
EXECUTIVE SUMMARY


PURPOSE 

To determine whether or not physicians uniformly and accurately use new visit codes 

adopted by the Health Care Financing Administration in 1992. 

BACKGROUND 

The Health Care Financing Administration (HCFA) bases Medicare payments to 

physicians partly on a system of five-digit codes. Generally, the codes represent type and 

complexity of service provided, and patient status, such as new or established. Medicare 

payments are generally higher for more complex and longer visits. 

Effective in 1992, HCFA adopted new visit codes developed by the American Medical 

Association (AMA). The AMA revised the previous coding system used by Medicare, 

and redefined physician services those codes represent. 

The revised codes were designed to improve coding uniformity and accuracy. Uniform 

coding is achieved when codes physicians submit to Medicare reflect a consistent pattern 

throughout a universe of physicians. Accurate coding is achieved when physicians select 

codes which consistently fit the services physicians actually provided. 

METHODOLOGY 

We drew our data from two sources. 

First, we surveyed eight randomly selected Medicare carriers to determine how they 

implemented and monitored the new codes. As part of that effort, we asked appropriate 

personnel from each carrier to code clinical vignettes to measure carrier accuracy and 

consistency in selecting correct codes. All eight carriers responded to our survey. 

Second, we randomly surveyed 328 physicians concerning their experiences with the new 

visit codes. Despite a number of follow-up attempts, only 61 physicians (18 percent) 

responded to our survey. Of the 328 physicians surveyed, 101 were primary care 

physicians. We asked the primary care physicians to code five clinical vignettes designed 

to measure how accurately and consistently physicians chose correct codes. Of the 101 

primary care physicians, 14 (13 percent) completed the vignettes. 

Because of low response rates to the physician survey, we cannot draw definitive 

conclusions regarding the experience of physicians in using new visit codes or their 

understanding of new visit codes. Nonetheless, we believe the data we did obtain may 

provide useful insight to HCFA. Therefore, we presented it in this report. 

i 

— .— — 
~ HAVE DIFFICULTY SELECTING NEW CODES 

None of the five vignettes were coded the same way by all sampled carriers, which 

illustrates carrier difficulty understanding the new visit codes. The vignettes were coded 

with a one level discrepancy, or carriers conceded they were unable to decide between 

two possible codes. Further, most carriers said (1) code definitions are not clear, and (2) 

they believe that physicians are not using the codes uniformly and accurately. 

PHYSICIANS HAD DIFFICULm SELECI’ING CODES 

The 14 physicians who coded our test vignettes also demonstrated difficulty selecting the 

codes accurately. Only 1 of the 14 physicians coded all 5 of the vignettes correctly as 

defined by the AMA. Many of the 61 physicians who responded to our survey frequently 

delegate code selection to their office staff. 

CARRIERS HAVE TAKEN LIMITED ACTION TO ENFORCE COMPLIANCE 

WJTH NEW VISIT CODES 

Carriers we surveyed said that, since the new visit codes were implemented in 1992, they 

have taken virtually no action against physicians for submitting improperly coded claims. 

RECENT HCFA GUIDANCXl MAY IMPROVE CODING UNIFORMITY AND 

ACCURKX 

Since the time of our survey, HCFA and the AMA have collaborated on, and 

disseminated medical record documentation guidelines. HCFA staff expect the 

guidelines to result in more uniform and accurate coding. The guidelines, issued in 

November 1994, are designed to clarifi criteria for visit codes. 

CONCLUSIONS 

Because of limited responses by physicians, the information presented in this report 

should be viewed as prelimina~. We make no recommendations. However, our data 

does raise concerns or questions about use of new visit codes, Those concerns are (1) 

the accuracy of codes selected by physicians, (2) the ability of carriers to correctly advise 

physicians on coding matters, and (3) the extent to which carriers effectively and 

appropriately monitor physician use of the codes. These concerns will be addressed in 

future reports by the OIG. 

11 

— 
� 

� 

� 

� 

TABLE OF CONTENTS


PAGE 

momma.. . . . . . ............ .............................. I�

Carrier Difficul~With The Codes . . . . . . . . . . . . . . . . . .


. . . . . . . .m.mm 4


Physician Difficul~With The Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . ..7


Limited Enforcement By Carriers . . . . . . . . . . . . . . . . . .


. . . . . . . . . . . . . 8


Recent HCFAGuidance . . . . . . . . . . . . . . . . . .


. . . ..O . . . ..O . . . . . . . 8


mN~USIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...9


APPENDICES


& Vignettes Coded By Carriers, hd Family hd General Practitioners . . . . . . A-1


B: Vignettes Coded By Internists . . . . . . . . . . . . . . . . . .


. . . . . . .OO... . . . . . . B-1


—.. 
INTRODUCTION


PURPOSE 

To determine whether or not physicians uniformly and accurately use new visit codes 

adopted by the Health Care Financing Administration in 1992. 

BACKGROUND 

The Health Care Financing Administration (HCFA) bases Medicare payments to 

physicians partly on a system of five-digit codes. Generally, the codes represent type and 

complexity of service provided, and patient status, such as new or established. Medicare 

payments are generally higher for more complex and longer visits. For example, a 

Medicare patient visit involving an in-depth examination for symptoms indicative of 

cancer would receive a higher payment code than a less complex visit for symptoms of a 

common cold. 

Medicare Pre-1992 Visit Codes and Related Problems 

From 1983 through 1991, the coding system used by HCFA did not result in uniform and 

accurate billing by physicians. Over that time period, various organizations, including 

Medicare carriers, Office of Inspector General (OIG), and HCFA identified coding 

problems that led to inappropriate Medicare payments. 

For example, in 1989, an OIG inspection report (OAI-04-88-O0700) showed that the 

coding system did not evidence “even a semblance of the uniformity sought” in physician 

billing. Physician use of codes for billing Medicare varied widely. Based partly on the 

OIG report, the American Medical Association (AMA), HCF~ and other agencies have 

studied the coding system over the last several years. The OIG and other reviewers 

generally described the coding problems as follows. 

k	 Vague code descriptions resulted in differences in physician interpretation of 

services each code represented. 

~	 Physicians apparently sought to maximize reimbursement by billing a higher level 

code than appropriate for services rendered. 

F	 HCFA and Medicare carriers did not consistently review and challenge coding 

practices by physicians. 

1

--

--

New vii axk 

Effective in 1992, HCFA adopted new visit codes developed by the AMA. That is, AMA 

revised the previous coding system Medicare and other insurers use. The AMA also 

redefined the physician services those codes represent. Like the previous codes, the new 

codes consist of five digits. 

The revised codes were designed to improve coding uniformity and accuracy. Although 

coding uniformity and accuracy are related goals, the terms are not synonymous. 

Uniform coding is achieved when codes physicians submit to Medicare reflect a 

consistent pattern throughout a universe of physicians. For example, five new codes 

represent the five alternative levels of complexity which gauge services physicians provide 

during office visits with established patients. If, nationally, physicians select the third 

level code about 52 percent of the time, but physicians in several States select it only 

about 30 percent of the time that would be a lack of uniformity. 

Coding accuracy is achieved when physicians select codes which fit the services actually 

provided. Using the above scenario as an example, any time a particular physician 

selects a code which represents an office visit of lesser or greater complexity than that 

which was actually provided that is inaccurate coding. Generally, to assess coding 

accuracy, a Medicare carrier must review a physician’s medical records supporting 

specific services that were billed. 

The pre-1992 visit codes included virtually no descriptive information which physicians 

could use to accurately select a code. Those codes represented services which were 

described only as “brief, “ “limited,” or similar subjective wording. Contrastingly, the 

revised definitions established much more specific, but elaborate, criteria for each code. 

The revised definitions included up to seven components of a visit. They were (1) 

medical history, (2) examination, (3) medical decision making, (4) counseling, 

(5) coordination of care, (6) nature of the presenting problem, and (7) an estimated 

amount of time physicians typically spend providing a service. The codes for the more 

complex services require more components than do codes for less complex services. 

The new coding system also reduces the number of codes available for use. This change 

was designed to reduce opportunities for erroneous interpretation of codes when 

physicians bill for services. 

METHODOLOGY 

We conducted structured interviews with HCFA headquarters staff to determine 

procedures HCFA used to implement the new visit codes. 

We surveyed eight randomly selected Medicare carriers to determine how they 

implemented and monitored the new codes. We mailed each carrier a standardized 

questionnaire. All eight carriers completed our questionnaire. However, we 

supplemented the written responses by visiting one carrier and telephoning the remaining 

2 
--

seven. We also asked appropriate personnel from each carrier to code five clinical


vignettes to measure carrier accuracy and uniformity in selecting codes.


We surveyed 328 physicians to determine how they used the new codes. We used


HCFA’S automated Unique Physician Identification Numbers file to randomly sample 360


physicians who were served by one of the eight Medicare carriers we had selected.


However, we dropped 32 physicians from our sample because of unknown addresses,


deaths, and retirements. We mailed standardized questionnaires to the remaining 328


physicians. A total of 61 physicians returned completed questionnaires, for a response


rate of 18 percent. Physician participation in our survey was voluntary.


Our sample of 328 physicians included 101 primary care physicians. Primary care


physicians are those in family and general practice and those in internal medicine. To


determine if physicians uniformly and accurately use the new codes, we asked the


primary care physicians to code five clinical vignettes as they would code an actual office


visit. We did not send test vignettes to sampled physicians in other specialties because


the number of sampled physicians in any one specialty was very small.


The 101 primary care physicians to whom we sent vignettes included 56 family and


general practitioners and 45 internists. We sent one set of five vignettes to family and


general practitioners, and a different set of five to internists. The set we sent to family


and general practitioners was the same as the set we sent to carriers. Fourteen


physicians coded and returned the vignettes a completion rate of 13 percent.


Appendix A shows the vignettes we sent to family and general practitioners and carriers.


Appendix B shows the vignettes we sent to internists.


The vignettes we used were furnished to us by the AMA. The AMA also provided the 

appropriate visit code for each vignette. We used AMA’s coding as a standard for 

determining if physicians coded the vignettes accurately. 

Because of the low response rates to the physicians’ survey, we cannot draw definitive 

conclusions regarding the experience of physicians in using new visit codes. Nonetheless, 

we believe the data we obtained will provide useful insights to HCFA and are therefore 

presented in this report. 

We conducted this inspection in accordance with the Quali& Standards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

3

FINDINGS


CARRIERS HAVE DIFFICULTY SELECI’ING NEW CODES 

Lack of Cothg Uniformity among Cam% 

To assess coding uniformity, we analyzed responses to five test vignettes coded by the 

eight sampled carriers. 

The vignettes we sent to carriers described office visits provided by a physician to an 

established patient. Five new visit codes represent various levels of complexity for office 

visits with such patients. The codes are 99211, 99212, 99213, 99214, and 99215. 

Notably, none of the five vignettes were coded the same way by all sampled carriers. 

The vignettes were coded with a one level discrepancy, or carriers conceded they were 

unable to decide between two possible codes. The following pattern was typical. 

b	 In coding one of the vignettes, three carriers selected code 99214, while three 

carriers selected 99215. The other two carriers were unable to decide between 

those two codes. The correct code, according to the AMA, was 99215. 

F	 For another vignette, four carriers selected code 99214, and three carriers selected 

99215. The remaining carrier was unable to decide between 99214 and 99215. 

The correct code was 99214, according to AMA. 

b	 For another vignette, three carriers selected code 99213. Four carriers selected 

99214. The remaining carrier was unable to decide between 99213 and 99214. 

The correct code was 99214, according to AMA. 

The lack of uniform coding was similar to HCFA findings in 1992. To assess uniformity, 

HCFA staff in a regional office had 4 Medicare carriers code 14 actual physician visits. 

The carriers coded the visits based on medical records supplied by physicians who had 

submitted Medicare claims. The visits were for hospital and other types of medical care. 

None of the 14 visits, however, were coded the same way by all 4 carriers. HCFA found 

that the 4 carriers selected between 2 and 4 different codes for each of the 14 visits. 

b Ten visits were coded two different ways. 

b Three visits were coded three different ways. 

b One visit was coded four different ways. 

4

--

Luck of Clear Code De@tions 

Six of the eight carriers we surveyed said the new visit codes are not clear. Most of those 

carriers said lack of clear definitions was the root cause of most coding problems. 

For example, one carrier specified that a clearer definition was needed to differentiate 

two levels of medical history and examination “problem focused” history and 

examination, as opposed to “extended problem focused” history and examination. Those 

terms are part of the definitions for office visit codes 99212 and 99213, respectively. 

The terms are supposed to help physicians differentiate the levels of complexity those 

two codes represent. Specifically, the levels of history and examination are two criteria 

for selecting code 99212 or 99213. 

Further describing the lack of clarity in the code definitions, another carrier stated that 

clarification was needed regarding how to properly evaluate medical decision making. 

The carrier also stated that clarification was needed on how to determine the degree of 

documentation needed to support each code level. For example, what documentation is 

needed on initial examinations as opposed to subsequent examinations. Some carriers 

also said they need examples of proper support documentation. (Subsequent to our 

survey, HCFA issued medical documentation guidelines to carriers.) 

Citing another aspect of the new codes for which they believe clarification is needed, 

several carriers said that they and physicians need more published vignettes giving 

examples of proper coding. They especially cited a need for vignettes on services to 

elderly persons with multiple ailments. 

Carriers Repti tick of Coding Un~ormity and Accuracy among Physkians 

We also asked carriers for their views about coding uniformity and accuracy. As Tables 

1 and 2 indicate, only carriers # 2 and # 4 in our sample believe that physicians are 

using the codes uniformly and accurately. The eight sampled carriers based their 

opinions that physicians used the new codes inaccurately or accurately on reviews of 

physician coding practices and medical records of patients. All of the carriers reported 

reviewing samples of Medicare claims and supporting documentation, as required by 

HCFA. However, in light of their own difficulties with choosing correct codes, carrier 

opinions should be viewed with some caution. 

5

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

TABLE 1


CARRIER OPINIONS ON UNIFORMITY OF CODING BY PHYSICIANS 

CARRIER UNIFORM NONUNIFORM DOIWI’KNOW 

Carrier # x


Carrier # x


Carrier # x


Carrier # x


Carrier # x


Carrier # x


Carrier # x


Carrier #


m 3 : 1


TABLE 2


CARRIER OPINIONS ON ACCURACY OF CODING BY PHYSICIANS


CARRIER 

Carrier #


Carrier #


Carrier #


Carrier #


Carrier #


Carrier #


Carrier #


Carrier #


m


ACCURATE INACCURATE DON’T KNOW 

x 

x 

x 

x 

x 

x 

x 

3 : 2 

6

PHYSICMS HAD DIFFI~~ 

The 14 physicians who coded the 

selecting proper codes (see Table 

Only one physician had a perfect 

SELE~G CODES 

test vignettes included in our survey also had difficulty 

3). The 14 physicians each coded 5 test vignettes. 

score, with five of five coded correctly as defined by the 

TABLE3 

AMA. 

PHYSICm 

5 of 5 correct 

4 of 5 correct 

3 of 5 correct 

2 of 5 correct 

1 of 5 correct 

0 of 5 correct 

Physician total 

P


CODING OF TEST CLNCfi VIG~m 

# OF PHYSICIANS 

1 

2 

6 

3 

1 

‘% 

II 14 

tick ofPhysicianInvolvement in selectin~ ~d~. ---0 -.— 

Our survey of physicians showed that most do not personally select codes for Medicare 

claims. Table 4 shows that only about 48 percent (29 of 61) of the physicians who 

responded to our survey said they selected the codes for billing Medicare 100 percent of 

the time. About 16 percent of the physicians said they never select the codes. Thus, 

they always delegate code selection to their staff. 

PHYSIC~ INVOLVE~~ 

FREQUENCY OF CODE # 

SELE~ON 

100 % of the time 

75-99 % of the time 

1-74 % of the time 

0 % of the time 

Total 

& 

TABLE 4 

IN CODING MEDIC- CLAIMS 

OF PHYSICIANS % OF PHYSICIANS 

29 48 % 

13	 21 % 

15 % 

16 % 

~ 100%

7


—. 

II 
CARRIERS HAVE TAKEN LIMK13D ACTION TO ENFORCE COMPLIANCE 

WITH NEW VISIT CODES 

Carriers report that, since the new visit codes were implemented in 1992, they have taken 

virtually no action against physicians for submitting improperly coded claims. 

During the first few months of 1992, HCFA instructed carriers to review claims, detect 

coding errors, and educate physicians accordingly. During 1992, at least four of the eight 

carriers we surveyed found error rates in excess of 25 percent. Such error rates might be 

expected the first few months after the new codes were implemented. Accordingly, 

HCFA took the approach of educating, rather than penalizing, physicians who used the 

wrong codes. However, since early 1992, physicians have had ample time to learn the 

new codes. Yet, carrier oversight and corrective actions have been minimal to date. 

HCFA told us that carriers and physicians were disadvantaged without guidelines on visit 

code criteria and related medical documentation. However, HCFA’S position is that 

earners could take corrective action if physicians egregiously miscode claims. 

Notwithstanding HCFA’S position on corrective action, the carriers we surveyed clearly 

indicated an understanding to the contrary. For example, carriers said they believed that 

HCFA had instructed them not to correct codes erroneously billed by physicians, and not 

to take corrective action. Further, one carrier expressed an opinion that HCFA had 

even discouraged monitoring of the new visit codes. Information from another earner 

illustrates carriers’ understanding of HCFA’S instructions regarding corrective actions. 

That carrier told us in May 1994 that some physicians were miscoding their claims and 

cited as an example a physician who billed all visits at the highest reimbursement level. 

The carrier did not complete an audit of the physician’s claims until February 1995. The 

audit showed that all of 60 claims reviewed should have been denied or downcoded. In 

spite of such an egregious finding, however the carrier still felt the need to seek further 

guidance from HCFA HCFA responded by acknowledging that carriers have been 

“restricted” in enforcing compliance with the new codes. However, HCFA restated its 

position that carriers, at their discretion, could take corrective action in egregious cases. 

RECENT HCFA GUIDANCE MAY IMPROVE CODING UNIFORMITY AND 

ACCURACY 

Subsequent to our surveys, HCFA issued guidelines to carriers on visit code criteria and 

supporting medical documentation. The guidelines, effective in November 1994, 

elaborate on visit code components such as medical history, examination, and medical 

decision making. HCFA reports that carriers are now engaged in an effort to educate 

physicians about the new guidelines. HCFA staff expect the guidelines to result in more 

uniform and accurate coding and more consistent medical review. Further, HCFA has 

provided carriers with computer software which can help them identify aberrant physician 

billing patterns. Potentially, carriers can use the software to lay a foundation for 

corrective actions against physicians who miscode Medicare claims. Beginning in August 

1995, HCFA expects carriers to step up enforcement of the new visit codes. 

8

CONCLUSIONS


Because of the limited physician response to our survey, we are not making 

recommendations. In light of the low response rates, the information we developed . . 

should be viewed as preliminary in nature. However, the data we collected in the course 

of our study raise certain questions. Among those questions are: 

How accurate are codes selected by physicians and/or their staffs when submitting 

claims to the Medicare program? 

In light of their own difficulty in selecting codes accurately, to what extent do 

carrier personnel have the ability to pro;ide good advice _tophysicians and their 

staffs on coding matters? 

To what extent are carrier personnel effectively and appropriately monitoring 

physicians’ use of codes? 

Future OIG work is planned in all three of these areas to assess whether HCFA’S new 

guidelines have the i;tended effect, and if so, how. HCFA expects its new guidelines to 

improve physician coding accuracy, carrier accuracy in giving advice, and carrier 

monitoring. 

9

APPENDIX A 

VIGNETTES CODED BY CARRIERS, AND FAMILY AND GENERAL 

PRAmoNERs 

A-1 
A.	 A sixty-six year old white male presents to the family physician’s office for a 

routine four month follow-up of his long standing hypertension and stable 

coronary artery disease. His past medical history is otherwise benign, and these 

chronic problems have remained stable for one to two years on single long acting 

calcium channel blocker. The patient, however, related the onset of new 

symptoms over the past four to six months including significant nocturia, hesitancy, 

and postvoid dribbling. A detailed examination is conducted including cardiac, 

pulmonary, and funduscopic examinations. All are within normal limits and 

unchanged. His abdominal exam, however, suggests a distended bladder and his 

rectal examination reveals a significantly enlarged prostate which is smooth, 

symmetric, and not suggestive of carcinoma. The patient is continuing on his 

usual medications but is counseled regarding a presumptive diagnosis of benign 

prostatic hypertrophy. A routine urinalysis is obtained along with an electrolyte 

panel, including renal function studies. The patient was scheduled for a urological 

consultation regarding the need for a transurethral resection of the prostate. He 

is scheduled for routine follow-up in one month following the urology evaluation. 

Duration of the visit is 12-25 minutes. 

Code: 99214 

B.	 A sixty-eight year old white female presents to the family physician’s office with a 

known history of moderate hypertension and Type 11 diabetes mellitus. She has 

missed her two previous scheduled appointments. The patient is known to be 

relatively noncompliant with her medical regimen. She is complaining of excessive 

fatigue over the past two months and increased frequency of urination 

accompanied with polydipsia and polyphagia. Her chronic medications are 

supposed to include a calcium channel blocker and an oral hypoglycemia agent. 

She does have the facilities at home to monitor her blood pressure at home as 

well as a home glucose monitor. A detailed history and physical are completed 

during this visit and it is obvious that she has again been noncompliant with her 

medical regimen and noncompliant with her diet. A review of her blood pressure 

readings from home, as well as her blood glucose readings have revealed poor 

control both of her hypertension and her diabetes mellitus. Appropriate 

arrangement are made through a home health agency to provide dietary 

counseling and to provide nursing visits to assist in the assurance of medication 

compliance as well as for blood pressure and diabetic monitoring at home. A 

return appointment is made for one week to assure improvement in her clinical 

status. Duration of the visit was 20-25 minutes. 

Code: 99214 

A-2

c.	 A seventy-seven year old black man presents to the family physician with a three 

month history of episodic substernal chest tightness with exertion. The patient is 

an established patient having been seen previously for routine physical exams and 

for other acute episodic illnesses. A complete history reveals the patient to be a 

long term abuser of tobacco, and he also has a very strong family history of 

coronary artery disease and hypertension. He states that his episodes of chest 

discomfort have been more progressive over the previous three months and now 

include radiation into his left shoulder and neck after limited exertion activity. 

The discomfort will usually subside within two or three minutes after exertion. A 

complete physical examination is undertaken which is unremarkable. Laboratory 

data reveals a normal chest x-ray and normal resting electrocardiogram. A 

presumptive diagnosis of coronary artery disease is made and the patient is 

prescribed a calcium channel blocker with the prn use of sublingual nitroglycerin. 

He is advised to discontinue his smoking and to limit his activities such that it is 

not to include heavy exertion or lifting. Specific counseling was also undertaken 

with the patient for coronary artery disease, risk factor modification. An 

appointment is made with a local cardiologist to schedule a submaximal exercise 

treadmill test and a follow-up appointment is scheduled in two weeks. Duration 

of time is 20-35 minutes. 

Code: 99214 

D.	 A fifty year old white female presented to her family physician because of the 

onset of erythema, edema, and pain in the area of the plantar surface of the right 

third metatarsal. This is an established patient known for her insulin dependent 

diabetes who is taking a split dose of Humulin N each day. The patient also has 

hypertension, which is well controlled on Procardia XL 30 mg daily. The patient 

does have the capacity to monitor her glucoses at home. The patient denies any 

fever but has begun to note “red streaks” radiating up the medial aspect of her 

foot. A complete physical examination is performed and was benign except for an 

area of deep cellulitis on the plantar surface of the right foot near the distal third 

metatarsal. There was evidence of ascending lymphangitis. The patient’s random 

glucose taken in the office was 250. The patient and her family were counseled at 

length regarding the acute diagnosis and the ability to provide appropriate care at 

home as an outpatient. Coordination of patient’s care was then initiated through 

a home health agency to provide intravenous home antibiotic therapy and to assist 

the patient in monitoring her blood glucose control. Arrangements were also 

made for daily outpatient whirlpool treatments for appropriate debridement and 

cleansing of the right foot if an ulcer were to develop. A follow-up appointment 

in two days was assigned to the patient. Duration of the visit, including face-toface time with the patient and her family, was 30 to 50 minutes. 

Code: 99215 

A-3

E.	 A seventy year old female is brought to the family physician by her daughter 

because of the onset over a two-month period ofconfusion, agitation, and short 

term memory loss. The patient iswellknown tothephysician because of the long 

standing history of hypertension and diet controlled diabetes mellitus. Her only 

medication is a thiazide diuretic. The patient is ambulatory but is clearly 

disoriented and becomes easily agitated. History obtained from the daughter 

suggests a possible history of a fall at home three to four months prior to this visit 

and no other trauma can be ascertained. A history and physical examination are 

conducted. This includes an extensive necrologic examination which reveals 

significant changes in the patient’s mental status examination but no focal 

necrologic findings. Bilateral carotid bruits are detected but there is no cardiac 

murmur. Multiple diagnoses are considered including multi infarct dementia, 

subdural hematoma, Alzheimer’s dementia, etc. Diagnostic testings is initiated, 

including a head scan and appropriate biochemical studies. A consultation is 

scheduled for a necrologic second opinion and a follow-up appointment is 

scheduled in two to three weeks. Her daughter is counseled concerning her 

mother’s potential differential diagnosis and suggestion are made concerning 

increasing her support and stimulation at home through semices offered by a local 

home health agency. A referral is made to this agency to assist the daughter with 

care of the patient at home. Duration of the visit spent with the patient and her 

family is 30-50 minutes. 

Code: 99215 

A-4

VIGNEl!lE CODED BY INTERNISTS 

B-1 
A.	 This is a 79 year old man who has had multiple basal cell carcinomas of the head 

and neck removed in the past. He is seen today in a cancer surveillance follow-up 

program. He has no complaints. 

You examine his skin and note no new lesions or recurrence of lesions from 

previous excision sites. You again educate him regarding sun exposure and 

schedule a follow-up appointment. 

You spend 15 minutes face-to-face with the patient and/or family. 

Code: 99213 

B.	 This is a 62 year old white female, established patient who is followed by you for 

primarily systolic hypertension. She presents in your office for a scheduled followup visit. She is on Dyazide. She has no complaints except for some urinary 

frequency. You obtain an interval history relating to her hypertension and GU 

symptomatology. 

You check her blood pressure which is well controlled and order a potassium and 

a urinalysis. 

You advise her to call tomorrow for the results. 

You spend 15 minutes face-to-face with the patient and/or family. 

Code: 99213 

c.	 A 55year old obese white male established patient comes to your office for 

routine follow-up six months following an anterior myocardial infarction. His 

medications include Procardia XL 30 mg. p.o. q.d., and Tenormin 25 mg. for 

hypertension. You obtain an interval history which is unremarkable. 

On examination, you note that his weight is down from 285 to 265 pounds. His 

height is 6’1” and his blood pressure is 105/65. He appears obese. His lungs are 

clear. You note an atrial diastolic gallop. 

You counsel him with regard to cholesterol management and advise him to 

continue his weight reduction and activity level. You make a note to consider 

dropping the Tenormin if his blood pressure remains stable. You schedule a 

return visit in one month. 

You spend 15 minutes face-to-face with the patient and/or family. 

Code: 99213 

B-2

D.	 A 68year old white female established patient presents to your office with a 

known histo~ of moderate hypertension and Type II diabetes mellitus. She has 

missed her two previous scheduled appointments. She is known to be relatively 

noncompliant with her medical regimen. She complains of excessive fatigue over 

the past two months and increased frequency of urination accompanied with 

polydipsia and polyphagia. Her chronic medications are supposed to include a 

calcium channel blocker and an oral hypoglycemic agent. She has the equipment 

at home to monitor her blood pressure and her blood glucose. You perform a 

detailed history and determine that she has again been noncompliant with her 

medical regimen and her diet. You review her blood pressure readings from 

home, as well as her blood glucose readings and note poor control of her 

hypertension and her diabetes. 

You perform a detailed physical. 

You adjust her hypertensive medication and arrange dietary counseling and 

nursing visits through a home health agency to assist in the assurance of 

medication compliance. You make a return appointment for one week to assure 

improvement in her clinical status. 

You spend 35 minutes face-to-face with the patient and/or family, 

Code: 99214 

E.	 An unemployed 60 year old man, a chronic heavy drinker of ethanol and smoker 

of cigarettes (two packs per day for 40 years), is brought to your office by his 

daughter. He has had gradual progressive shortness of breath for 2 years and a 

long-term daily cough, usually productive of clear phlegm. However, 5 days ago, 

after binge drinking, he notices that the phlegm was no longer clear but purulent 

and occasionally streaked with blood. The patient was told that he had a positive 

tuberculin skin test many years ago, but he never received antituberculosis 

medication. 

Your physical examination reveals the patient to be alert but weak, disheveled, 

and ill-appearing. His mouth and gums are in poor condition. There is no 

adenopathy. Examination of the chest reveals scattered wheezes and a prolonged 

expiatory phase. There is clubbing of his fingers, but the rest of his physical 

examination shows no abnormalities. 

You order laboratory studies and send the patient to the second floor of your 

professional building for a chest x-ray. Within 20 minutes the radiologist reports 

that the roentgenograph of the chest shows an irregular, thick walled cavitary 

lesion in the right lung. 

The patient and his daughter come into your office where you tell them of the 

findings on the x-ray and suggest hospitalization. The patient becomes agitated, 

B-3