Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
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An otherwise healthy established office patient with a cold
CC : “ Cough and congestion.”
Interval History : Patient states he developed nasal congestion and a runny nose about five days ago. More recently, these symptoms have been associated with a non-productive cough.
Physical Ex am
General appearance: No acute distress; conversant
Vitals: 98.6, 72, 20, 110/74
HEENT: Oropharynx is clear with normal posterior pharynx without erythema or exudate.
Lungs: CTA
Assessment
- Common cold
Plan
- Push fluids
- Rest
- Tylenol, if needed
For a detailed breakdown of this note with tips and advice see 99212 E/M Insight
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