Initial Hospital Care (99221, 99222, 99223)

Case 1: Initial Hospital Care - Code 99221

Patient Name: Michael Turner

Age: 62
Gender: Male
Date of Admission: 06/25/2024

Chief Complaint:

Dizziness and palpitations.

History of Present Illness (HPI):

Michael Turner, a 62-year-old male, presents with a 2-day history of intermittent dizziness and
palpitations. He describes the dizziness as a feeling of lightheadedness, especially when standing
up quickly. He has also noticed a fluttering sensation in his chest. He denies any chest pain,
shortness of breath, or syncope. He recently started a new antihypertensive medication.

Past Medical History (PMH):

 Hypertension
 Hyperlipidemia

Past Surgical History (PSH):

 Knee arthroscopy at age 45

Social History:

 Non-smoker
 Occasional alcohol use
 Retired accountant

Review of Systems (ROS):

 General: No fever or chills.

 Cardiovascular: Positive for palpitations, no chest pain.
 Respiratory: No shortness of breath or cough.
 Gastrointestinal: No nausea or vomiting.
 Neurological: Positive for dizziness, no focal weakness.

Physical Examination:

 Vital Signs: BP 140/85, HR 88 bpm, RR 16, Temp 98.6°F, SpO2 97% on room air.
  General: Appears well, no acute distress.
 HEENT: No JVD, normal oral mucosa.
 Cardiovascular: Regular rhythm, no murmurs or gallops.
 Respiratory: Clear to auscultation bilaterally.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert and oriented, no focal deficits.
 Extremities: No edema, normal pulses.

Diagnostic Tests:

 EKG: Normal sinus rhythm, occasional premature atrial contractions.

 CBC: Normal.
 CMP: Normal electrolytes, renal function within normal limits.

Assessment:

1. Dizziness, likely orthostatic hypotension.

2. Palpitations, possibly related to premature atrial contractions.
3. Hypertension, under treatment with new medication.

Plan:

 Monitor vital signs, especially orthostatic measurements.

 Review and possibly adjust antihypertensive medication.
 Encourage hydration and advise slow positional changes.
 Follow-up with cardiology if palpitations persist.

Coding Explanation:

99221 is chosen due to the relatively straightforward nature of the visit, which includes a detailed
history, detailed examination, and low to moderate complexity in decision-making. The
physician typically spends around 30 minutes at the bedside or on the hospital floor/unit.

Case 2: Initial Hospital Care - Code 99222

Patient Name: Susan Davis

Age: 58
Gender: Female
Date of Admission: 06/25/2024

Chief Complaint:

Worsening shortness of breath and leg swelling.

History of Present Illness (HPI):

Susan Davis, a 58-year-old female, presents with a 1-week history of worsening shortness of
breath and bilateral leg swelling. She reports difficulty breathing even at rest and cannot sleep
flat due to shortness of breath. She also noticed her legs becoming more swollen, particularly at
the end of the day. She has a history of congestive heart failure (CHF) and hypertension.

Past Medical History (PMH):

 Congestive heart failure (CHF)

 Hypertension
 Type 2 diabetes mellitus

Past Surgical History (PSH):

 Hysterectomy at age 50

Social History:

 Non-smoker
 No alcohol use
 Lives alone, retired teacher

Family History:

 Mother had CHF.

 Father had hypertension and diabetes.

Review of Systems (ROS):

 General: Fatigue, weight gain over the past week.

 Cardiovascular: Positive for swelling and orthopnea, no chest pain.
 Respiratory: Shortness of breath, especially on exertion.
 Gastrointestinal: No nausea or vomiting.
 Genitourinary: No changes in urination.
 Neurological: No dizziness or syncope.

Physical Examination:

 Vital Signs: BP 150/95, HR 105 bpm, RR 24, Temp 98.2°F, SpO2 92% on room air.
 General: Appears uncomfortable, mild respiratory distress.
 HEENT: No JVD, dry oral mucosa.
 Cardiovascular: Tachycardic, regular rhythm, S3 gallop.
 Respiratory: Bibasilar crackles.
 Abdomen: Soft, non-tender, no ascites.
 Neurological: Alert and oriented, no focal deficits.
  Extremities: Bilateral pitting edema up to the knees.

Diagnostic Tests:

 Chest X-ray: Pulmonary congestion.

 EKG: Sinus tachycardia.
 BNP: Elevated, suggestive of heart failure exacerbation.
 CBC: Mild anemia.
 BMP: Elevated BUN and creatinine, indicative of renal involvement.

Assessment:

1. Acute exacerbation of congestive heart failure.

2. Hypertension.
3. Type 2 diabetes mellitus.

Plan:

 Admit to telemetry unit for continuous monitoring.

 Start diuretics (IV furosemide) to reduce fluid overload.
 Adjust antihypertensive medications as needed.
 Monitor electrolytes and renal function closely.
 Cardiology consult for further management and optimization of CHF therapy.
 Daily weight and fluid balance monitoring.

Coding Explanation:

99222 is selected because the visit involved a detailed history and examination, along with
moderate complexity in medical decision-making. The physician typically spends around 50
minutes at the bedside or on the hospital floor/unit. The management of the patient’s CHF
exacerbation and other comorbidities justifies this level of care.

Case 3: Initial Hospital Care - Code 99223

Patient Name: Karen White

Age: 72
Gender: Female
Date of Admission: 06/25/2024

Chief Complaint:

Severe shortness of breath, high fever, and productive cough.

History of Present Illness (HPI):

Karen White, a 72-year-old female with a history of COPD and hypertension, presents with a 3-
day history of severe shortness of breath, high fever up to 102°F, and a productive cough with
purulent sputum. She has been feeling progressively worse, with difficulty breathing even at rest
and persistent chills. Over-the-counter medications have not improved her symptoms.

Past Medical History (PMH):

 Chronic obstructive pulmonary disease (COPD)

 Hypertension
 Osteoarthritis

Past Surgical History (PSH):

 Appendectomy at age 30

Social History:

 Former smoker (40 pack-years, quit 5 years ago).

 No alcohol or drug use.
 Lives with her husband, retired nurse.

Family History:

 Mother had COPD.

 Father had hypertension and stroke.

Review of Systems (ROS):

 General: Fever, fatigue, weight loss.

 Cardiovascular: No chest pain or palpitations.
 Respiratory: Severe shortness of breath, productive cough.
 Gastrointestinal: No nausea or vomiting.
 Genitourinary: No changes in urination.
 Neurological: No dizziness or syncope.

Physical Examination:

 Vital Signs: BP 145/85, HR 110 bpm, RR 30, Temp 101.8°F, SpO2 88% on room air.
 General: Appears ill and in respiratory distress.
 HEENT: Mild cyanosis of lips, dry oral mucosa.
 Cardiovascular: Tachycardic, regular rhythm, no murmurs.
 Respiratory: Use of accessory muscles, diffuse crackles and wheezes.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert but fatigued, no focal deficits.
 Extremities: No edema, normal pulses.
Diagnostic Tests:

 Chest X-ray: Bilateral infiltrates consistent with pneumonia.

 CBC: Elevated WBC count, suggestive of infection.
 BMP: Elevated glucose, normal electrolytes.
 ABG: Hypoxemia and respiratory acidosis.

Assessment:

1. Severe community-acquired pneumonia.

2. Acute exacerbation of COPD.
3. Hypertension.

Plan:

 Admission: Admit to ICU for closer monitoring due to respiratory distress and
hypoxemia.
 Antibiotics: Start broad-spectrum antibiotics (Levofloxacin and Ceftriaxone).
 Respiratory support: Initiate BiPAP to improve oxygenation.
 Fluids: Administer IV fluids cautiously to avoid fluid overload.
 COPD Management: Continue bronchodilators and steroids.
 Monitoring: Frequent ABGs, continuous pulse oximetry.
 Consultations: Pulmonology and infectious disease consults.
 Follow-up: Daily review of labs, cultures, and clinical status.

Coding Explanation:

99223 is chosen due to the complexity and severity of the patient's condition, which required a
comprehensive history, comprehensive examination, and high-complexity decision-making. The
physician typically spends around 70 minutes at the bedside or on the hospital floor/unit,
managing multiple serious conditions requiring intensive monitoring and treatment.

Subsequent Hospital Care (99231, 99232, 99233)

Case 4: Subsequent Hospital Care - Code 99231

Patient Name: Michael Turner

Age: 62
Gender: Male
Date of Service: 06/26/2024

Chief Complaint:

Follow-up for dizziness and palpitations.

Interval History:

Michael Turner is a 62-year-old male admitted yesterday for dizziness and palpitations. He
reports feeling better today with no further episodes of dizziness or palpitations. He has been
careful to change positions slowly and stay hydrated. No new complaints.

Physical Examination:

 Vital Signs: BP 135/80, HR 82 bpm, RR 16, Temp 98.4°F, SpO2 97% on room air.
 General: Appears well, no acute distress.
 HEENT: No JVD, normal oral mucosa.
 Cardiovascular: Regular rhythm, no murmurs.
 Respiratory: Clear to auscultation bilaterally.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert and oriented, no focal deficits.
 Extremities: No edema, normal pulses.

Assessment and Plan:

1. Orthostatic hypotension: Continue monitoring and encourage fluid intake.

2. Palpitations: No further episodes; continue to monitor.
3. Hypertension: Blood pressure well-controlled with current medications.

Coding Explanation:

99231 is appropriate for this follow-up visit, as it involves a problem-focused interval history
and examination, with straightforward or low complexity medical decision-making. The
physician typically spends around 15 minutes at the bedside or on the hospital floor/unit.

Case 5: Subsequent Hospital Care - Code 99232

Patient Name: Susan Davis

Age: 58
Gender: Female
Date of Service: 06/26/2024

Chief Complaint:

Follow-up for congestive heart failure exacerbation.

Interval History:
Susan Davis, a 58-year-old female admitted for CHF exacerbation, reports improved breathing
and less leg swelling after starting diuretics. She continues to have some shortness of breath with
exertion but feels better overall. Her weight has decreased by 3 pounds since admission.

Physical Examination:

 Vital Signs: BP 140/90, HR 95 bpm, RR 20, Temp 98.2°F, SpO2 94% on room air.
 General: Appears comfortable, less respiratory distress.
 HEENT: No JVD, dry oral mucosa.
 Cardiovascular: Regular rhythm, S3 gallop still present.
 Respiratory: Bibasilar crackles reduced.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert and oriented, no focal deficits.
 Extremities: Decreased pitting edema, now up to the ankles.

Assessment and Plan:

1. CHF exacerbation: Continue diuretics, monitor fluid status and electrolytes closely.
2. Hypertension: Blood pressure improved, continue current medications.
3. Type 2 diabetes mellitus: Monitor blood glucose levels and adjust insulin as needed.

Coding Explanation:

99232 is chosen for this follow-up visit due to the more detailed interval history, expanded
examination, and moderate complexity medical decision-making. The physician typically spends
around 25 minutes at the bedside or on the hospital floor/unit.

Case 6: Subsequent Hospital Care - Code 99233

Patient Name: Karen White

Age: 72
Gender: Female
Date of Service: 06/26/2024

Chief Complaint:

Follow-up for severe pneumonia and COPD exacerbation.

Interval History:

Karen White, a 72-year-old female, remains in the ICU for severe pneumonia and COPD
exacerbation. She reports some improvement in breathing with BiPAP but still feels weak and
fatigued. Fever has decreased slightly, and sputum production continues but is less purulent. She
denies any new symptoms.
Physical Examination:

 Vital Signs: BP 140/85, HR 100 bpm, RR 25, Temp 99.5°F, SpO2 92% on BiPAP.
 General: Appears fatigued but less distressed.
 HEENT: Mild cyanosis of lips, dry oral mucosa.
 Cardiovascular: Tachycardic, regular rhythm, no murmurs.
 Respiratory: Using accessory muscles, persistent crackles and wheezes.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert but tired, no focal deficits.
 Extremities: No edema, normal pulses.

Diagnostic Results:

 ABG: Improved oxygenation but still hypoxemic.

 CBC: WBC count trending down.
 Sputum culture: Growing Streptococcus pneumoniae.

Assessment and Plan:

1. Severe community-acquired pneumonia: Continue IV antibiotics, monitor for signs of

clinical improvement.
2. COPD exacerbation: Continue BiPAP, adjust bronchodilator therapy as needed.
3. Hypertension: Monitor blood pressure and adjust medications if necessary.
4. Hypoxemia: Continue oxygen therapy and frequent ABGs.

Coding Explanation:

99233 is selected due to the comprehensive interval history, detailed examination, and high-
complexity medical decision-making required for managing multiple severe conditions in a
critically ill patient. The physician typically spends around 35 minutes at the bedside or on the
hospital floor/unit.

Case 1: Hospital Inpatient/Observation Care - Code 99234

Patient Name: John Smith

Age: 45
Gender: Male
Date of Admission and Discharge: 06/25/2024

Chief Complaint:

Chest pain.

History of Present Illness (HPI):

John Smith, a 45-year-old male, presented to the emergency department with a 2-hour history of
chest pain. He describes the pain as a sharp, localized sensation in the left side of his chest,
occurring intermittently and worsening with deep breaths. He denies any radiation of the pain,
nausea, or sweating. No recent trauma or exertion reported. He has no significant past medical
history.

Past Medical History (PMH):

 None

Past Surgical History (PSH):

 Appendectomy at age 30

Social History:

 Non-smoker
 Moderate alcohol use
 Works as a construction manager

Family History:

 Father had a myocardial infarction at age 55.

 Mother has hypertension.

Review of Systems (ROS):

 General: No fever or weight loss.

 Cardiovascular: Chest pain localized to the left side.
 Respiratory: Pain with deep breaths, no shortness of breath or cough.
 Gastrointestinal: No nausea or vomiting.
 Neurological: No dizziness or syncope.

Physical Examination:

 Vital Signs: BP 130/80, HR 78 bpm, RR 18, Temp 98.6°F, SpO2 98% on room air.
 General: Appears comfortable, no acute distress.
 HEENT: No JVD, normal oropharynx.
 Cardiovascular: Regular rhythm, no murmurs.
 Respiratory: Clear to auscultation, no wheezing.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert and oriented, no focal deficits.
 Extremities: No edema, normal pulses.

Diagnostic Tests:
  EKG: Normal sinus rhythm, no ischemic changes.
 Troponin: Normal.
 Chest X-ray: No acute findings.
 CBC: Normal.
 BMP: Normal electrolytes and renal function.

Assessment:

1. Chest pain: Likely musculoskeletal in origin.

2. Hypertension: Well-controlled today.

Plan:

 Observation: Monitor in observation unit for 6 hours for any change in symptoms.
 Pain Management: Administer NSAIDs for pain relief.
 Discharge: If no new symptoms or changes, discharge with follow-up in primary care for
further evaluation.
 Instructions: Advise the patient on recognizing warning signs and when to seek
immediate medical attention.

Discharge Summary:

John Smith was monitored in the observation unit for 6 hours. His chest pain improved with
NSAIDs, and there were no further episodes of pain or any other concerning symptoms. He was
discharged with instructions to follow up with his primary care provider.

Case 2: Hospital Inpatient/Observation Care - Code 99235

Patient Name: Emma Johnson

Age: 68
Gender: Female
Date of Admission and Discharge: 06/25/2024

Chief Complaint:

Severe headache and nausea.

History of Present Illness (HPI):

Emma Johnson, a 68-year-old female, presented with a sudden onset of a severe headache
described as the "worst headache of her life." The pain began 4 hours before arrival and is
localized to the right side of her head. It is associated with nausea and light sensitivity. She
denies any trauma, recent infections, or similar headaches in the past. She has a history of
migraines but states this headache feels different.
Past Medical History (PMH):

 Migraine headaches
 Hypertension
 Hyperlipidemia

Past Surgical History (PSH):

 Cataract surgery at age 65

Social History:

 Non-smoker
 Occasional alcohol use
 Retired teacher

Family History:

 Mother had hypertension and migraines.

 Father had a stroke at age 70.

Review of Systems (ROS):

 General: No fever or chills.

 Cardiovascular: No chest pain or palpitations.
 Respiratory: No shortness of breath or cough.
 Gastrointestinal: Nausea but no vomiting.
 Neurological: Severe headache, no vision changes or weakness.

Physical Examination:

 Vital Signs: BP 155/90, HR 90 bpm, RR 18, Temp 98.4°F, SpO2 97% on room air.
 General: Appears in pain but alert.
 HEENT: No JVD, normal fundoscopic exam, no papilledema.
 Cardiovascular: Regular rhythm, no murmurs.
 Respiratory: Clear to auscultation, no wheezing.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert and oriented, cranial nerves intact, no focal deficits.
 Extremities: No edema, normal pulses.

Diagnostic Tests:

 CT Head: No acute intracranial findings.

 CBC: Normal.
 BMP: Normal electrolytes and renal function.
 LP: No signs of infection, normal opening pressure.
Assessment:

1. Severe headache: Likely a severe migraine vs. possible subarachnoid hemorrhage (SAH)
given the atypical nature.
2. Hypertension: Elevated, possibly related to pain.

Plan:

 Observation: Monitor closely for any neurological changes over 12 hours.

 Pain Management: Administer IV fluids and anti-migraine medications.
 Consultation: Neurology consult for further evaluation.
 Discharge: If stable and improved, discharge with neurology follow-up for potential
migraine management.

Discharge Summary:

Emma Johnson was observed for 12 hours with significant improvement in her headache after
treatment with IV fluids and migraine medication. No neurological changes were noted. She was
discharged with instructions to follow up with a neurologist for further migraine management
and to monitor her blood pressure.

Coding Explanation:

99235 is appropriate for this scenario because it involves a comprehensive history and
examination, with moderate complexity in medical decision-making. The patient’s admission
and discharge occurred on the same day, with the physician spending around 50 minutes
managing her care. This visit included evaluating for potential serious neurological conditions
and managing severe headache symptoms.

Case 3: Hospital Inpatient/Observation Care - Code 99236

Patient Name: Robert Green

Age: 70
Gender: Male
Date of Admission and Discharge: 06/25/2024

Chief Complaint:

Shortness of breath and fever.

History of Present Illness (HPI):

Robert Green, a 70-year-old male with a history of COPD and heart failure, presented with
worsening shortness of breath over the past two days and a fever of 101°F. He reports increased
sputum production, fatigue, and feeling generally unwell. He has been using his inhalers more
frequently but without relief. His wife notes he has been more confused than usual today.

Past Medical History (PMH):

 Chronic obstructive pulmonary disease (COPD)

 Congestive heart failure (CHF)
 Hypertension

Past Surgical History (PSH):

 Coronary artery bypass graft (CABG) at age 60

Social History:

 Former smoker (50 pack-years, quit 10 years ago).

 No alcohol use.
 Lives with his wife, retired engineer.

Family History:

 Father had COPD and died of heart failure.

 Mother had hypertension.

Review of Systems (ROS):

 General: Fever, fatigue, weight loss.

 Cardiovascular: No chest pain, palpitations, or edema.
 Respiratory: Increased shortness of breath, productive cough.
 Gastrointestinal: No nausea or vomiting.
 Neurological: Confusion, no focal weakness or seizures.

Physical Examination:

 Vital Signs: BP 145/85, HR 110 bpm, RR 26, Temp 100.8°F, SpO2 90% on room air.
 General: Appears ill, in moderate respiratory distress.
 HEENT: Mild cyanosis of lips, dry oral mucosa.
 Cardiovascular: Tachycardic, regular rhythm, S3 gallop.
 Respiratory: Use of accessory muscles, diffuse crackles and wheezes.
 Abdomen: Soft, non-tender, no organomegaly.
 Neurological: Alert but confused, no focal deficits.
 Extremities: No edema, normal pulses.

Diagnostic Tests:

 Chest X-ray: Bilateral infiltrates suggestive of pneumonia.

  EKG: Sinus tachycardia, no acute ischemic changes.
 ABG: Hypoxemia, respiratory acidosis.
 CBC: Elevated WBC count.
 BMP: Normal electrolytes, slight increase in BUN.

Assessment:

1. Severe pneumonia: Suspected community-acquired pneumonia exacerbating COPD.

2. Acute on chronic CHF: Likely contributing to respiratory symptoms.
3. Confusion: Likely multifactorial (infection, hypoxia).

Plan:

 Admission: Admit to inpatient for IV antibiotics, oxygen therapy, and close monitoring.
 Oxygen Therapy: Administer BiPAP for respiratory support.
 Antibiotics: Start broad-spectrum IV antibiotics.
 Diuretics: Administer IV diuretics to manage CHF exacerbation.
 Consultation: Pulmonology and cardiology consults.
 Observation: Monitor for 24 hours and reassess.

Discharge Summary:

After 24 hours of intensive treatment, Robert Green's respiratory status improved significantly
with oxygen therapy and IV antibiotics. His fever subsided, and his mental status returned to
baseline. Given the rapid response to treatment, he was discharged with home oxygen and oral
antibiotics, with instructions for close follow-up with his primary care physician and
pulmonologist.

Coding Explanation:

99236 is selected due to the comprehensive nature of the history and examination, and the high
complexity of medical decision-making involved. The patient’s admission and discharge on the
same day, with around 70 minutes spent in direct patient care, reflects the need for intensive
monitoring and management of multiple serious conditions.

These records illustrate the appropriate use of the 99234, 99235, and 99236 codes for hospital
inpatient or observation care services where admission and discharge occur on the same day,
reflecting different levels of care complexity and physician time spent.