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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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Office consultation for a female with a forearm contusion
Reason for consultation : Left arm pain
Requesting clinician : Jane Doe, ARNP
HPI : The patient is a 41 year old female referred from an urgent care clinic for left arm pain. She was playing tennis yesterday when she accidentally hit her left forearm with her own racquet.
Physical Exam
Left forearm has a slight bruise. No swelling or erythema; no effusion in the wrist. Normal grip strength
Assessment
- Left forearm contusion
Plan
- Rest
- No further treatment needed
- Re-evaluate PRN if no improvement in one week
- Will send a copy of this note to Jane Doe, ARNP
For a detailed breakdown of this note with tips and advice see 99241 E/M Insight
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