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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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An established office patient with osteoarthritis
CC : “ knee pain.”
Interval History : Patient with known osteoarthritis which had been previously controlled on Tylenol. Now states his left knee has been aching for about two weeks despite two to three doses of Tylenol per day.
ROS : Musculoskeletal--Negative for arthralgias or worsening joint pain elsewhere
Physical Exam
Mild swelling of left knee compared to the right. Some pain with passive rotation. No overlying warmth or erythema.
Assessment
- Worsening osteoarthritis
Plan
- Start OTC ibuprofen 400 mg po TID, PRN
- Return visit in two weeks if no improvement
For a detailed breakdown of this note with tips and advice see 99213 E/M Insight |
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