1. ENT –TMs clear and pearly-grey.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
2. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
ENT – EACs patient, TMs clear and pearly-grey, pharynx without exudate or erythema.
Respiratory –CTAB
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
3. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Cardiovascular –PMI non-displaced, RRR no m/r/g, no peripheral edema, 2+ dorsalis pedis pulses, 2+ radial pulses.
Respiratory – no respiratory distress, no chest wall tenderness, normal percussion, CTAB
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
4. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Cardiovascular –PMI non-displaced, RRR no rubs, or gallops. There is a III/VI systolic murmur heard at the R upper eternal border, holosystolic and harsh. 1+ BLE edema, 2+ dorsalis pedis pulses, 2+ radial pulses.
Respiratory – There is no respiratory distress or labored breathing, the chest wall expands fully and symmetrically. There is no tenderness on palpation or masses palpated on the chest wall. There is normal percussion throughout. Faint crackles auscultated in the lower lobes bilaterally; otherwise lungs are clear with no wheezes or ronchi.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
5. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
ENT – EACs patient, TMs clear and pearly-grey, pharynx without exudate or erythema.
Cardiovascular –RRR no m/r/g, no peripheral edema
Respiratory – no labored breathing, CTAB
GI –Normal abdomen inspection, +BS, soft/non-tender/no masses.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
6. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
GI –Normal inspection, +BS, soft/non-tender.
GU – normal inspection of vulva, no inflammation, discharge, or lesions of the vagina or cervix, nontender uterus, appropriate size, normal ovarian palpation, normal breast inspection, no breast masses palpated.
Lymphatic/Hematologic – lymph nodes of axilla and chest are normal.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
7. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Skin – diffuse maculopapular rash covering trunk with sandpaper texture.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
8. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Musculoskeletal – inspection, palpation, and range-of-motion normal in B knees, shoulders, and hips.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
9. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Eyes – no papilledema, extra-ocular muscles intact B, PERRLA, normal anterior chamber depth, conjunctiva and lids without injection or swelling
Neuro – Cranial nerves II-XII normal, 2+ knee reflexes B, 2+ ankle reflexes B, 5/5 strength in flexors and extensors of upper and lower extremities. No sensory defects in upper or lower extremities. Normal finger-nose-finger. .
Psych – mood, affect, orientation, judgment, and memory are normal.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
10. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
ENT –TMs clear and pearly-grey, pharynx without exudate or erythema.
Eyes –PERRLA, EOMI
Cardiovascular –RRR no m/r/g, no peripheral edema
Respiratory – no labored breathing, CTAB
GI –+BS, soft/non-tender
Musculoskeletal – inspection and palpation of B knee joints normal.
Skin – no rashes, normal palpation of skin.
Neuro – Cranial nerves II-XII normal, 2+ knee reflexes B.
Psych – A&Ox3, mood and affect normal.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
*answers below…
1. ENT –TMs clear and pearly-grey.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
2. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
ENT – EACs patient, TMs clear and pearly-grey, pharynx without exudate or erythema.
Respiratory –CTAB
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
3. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Cardiovascular –PMI non-displaced, RRR no m/r/g, no peripheral edema, 2+ dorsalis pedis pulses, 2+ radial pulses.
Respiratory – no respiratory distress, no chest wall tenderness, normal percussion, CTAB
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
4. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Cardiovascular –PMI non-displaced, RRR no rubs, or gallops. There is a III/VI systolic murmur heard at the R upper eternal border, holosystolic and harsh. 1+ BLE edema, 2+ dorsalis pedis pulses, 2+ radial pulses.
Respiratory – There is no respiratory distress or labored breathing, the chest wall expands fully and symmetrically. There is no tenderness on palpation or masses palpated on the chest wall. There is normal percussion throughout. Faint crackles auscultated in the lower lobes bilaterally; otherwise lungs are clear with no wheezes or ronchi.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
5. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
ENT – EACs patient, TMs clear and pearly-grey, pharynx without exudate or erythema.
Cardiovascular –RRR no m/r/g, no peripheral edema
Respiratory – no labored breathing, CTAB
GI –Normal abdomen inspection, +BS, soft/non-tender/no masses.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
6. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
GI –Normal inspection, +BS, soft/non-tender.
GU – normal inspection of vulva, no inflammation, discharge, or lesions of the vagina or cervix, nontender uterus, appropriate size, normal ovarian palpation, normal breast inspection, no breast masses palpated.
Lymphatic/Hematologic – lymph nodes of axilla and chest are normal.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
7. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Skin – diffuse maculopapular rash covering trunk with sandpaper texture.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
8. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Musculoskeletal – inspection, palpation, and range-of-motion normal in B knees, shoulders, and hips.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
9. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
Eyes – no papilledema, extra-ocular muscles intact B, PERRLA, normal anterior chamber depth, conjunctiva and lids without injection or swelling
Neuro – Cranial nerves II-XII normal, 2+ knee reflexes B, 2+ ankle reflexes B, 5/5 strength in flexors and extensors of upper and lower extremities. No sensory defects in upper or lower extremities. Normal finger-nose-finger. .
Psych – mood, affect, orientation, judgment, and memory are normal.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
10. General – HR 76, BP 123/87, RR 12, temp 98.4. No apparent distress.
ENT –TMs clear and pearly-grey, pharynx without exudate or erythema.
Eyes –PERRLA, EOMI
Cardiovascular –RRR no m/r/g, no peripheral edema
Respiratory – no labored breathing, CTAB
GI –+BS, soft/non-tender
Musculoskeletal – inspection and palpation of B knee joints normal.
Skin – no rashes, normal palpation of skin.
Neuro – Cranial nerves II-XII normal, 2+ knee reflexes B.
Psych – A&Ox3, mood and affect normal.
a. problem-focused exam (99212)
b. expanded-problem-focused exam (99202 or 99213)
c. detailed exam (99203 or 99214)
d. comprehensive exam (99204, 99205, or 99215)
Medical Coding and Billing For Residents 