Medications Encounter Code Set (1594)    NLM VALUE SETS (802.2)

Interactive individual medical psychotherapy (regime/therapy)

Manual pelvic examination (procedure)

Ophthalmic examination and evaluation (procedure)

Evaluation and management of new outpatient in office or other outpatient 
facility (procedure)

Examination of breast (procedure)

Acoustic reflex testing (procedure)

Evaluation and management of patient at home (procedure)

Basic comprehensive audiometry testing (procedure)

Positional nystagmus test with recording (procedure)

Caloric vestibular test with recording (procedure)

Ophthalmic examination and evaluation, follow-up (procedure)

Psychiatric interview and evaluation (procedure)

History and physical examination, annual for health maintenance (procedure)

Gynecologic examination (procedure)

Periodic reevaluation and management of healthy individual (procedure)

Initial evaluation and management of healthy individual (procedure)

Tympanometry testing (procedure)

Evaluation AND/OR management - new patient (procedure)

Evaluation AND/OR management - established patient (procedure)

Preventive patient evaluation (procedure)

Psychiatric procedure, interview AND/OR consultation (procedure)

Initial psychiatric evaluation (procedure)

Manual examination of breast (procedure)

Encounter for "check-up" (procedure)

Visit out of hours (procedure)

Weekend visit (procedure)

History and physical examination with management of domiciliary or rest 
home patient (procedure)

Domiciliary or rest home patient evaluation and management (procedure)

Self-care patient education (procedure)

Speech audiometry (procedure)

Evoked oto-acoustic emission measurement (procedure)

Patient-initiated encounter (procedure)

Provider-initiated encounter (procedure)

History and physical examination with evaluation and management of patient 
(procedure)

Neurobehavioral cognitive status examination (assessment scale)

Examination of tympanic membrane (procedure)

High frequency tympanometry (procedure)

Auditory evoked potentials monitoring (regime/therapy)

Patient encounter procedure (procedure)

Evaluation of psychosocial impact on plan of care (procedure)

Dialysis care management (procedure)

Nutrition management (regime/therapy)

Follow-up encounter (procedure)

Diabetes self-management behavior (observable entity)

Electronystagmography with vertical electrodes (procedure)

Urgent follow-up (procedure)

Renal care management (procedure)

Occupational therapy assessment (procedure)

Occupational therapy management (procedure)

Physical therapy assessment (procedure)

Physical therapy management (procedure)

Nutrition care assessment (procedure)

Home visit (procedure)

Evaluation of auditory rehabilitation (procedure)

Oscillating tracking test with recording (procedure)

Individual psychotherapy (regime/therapy)

Evaluation and management of established outpatient in office or other 
outpatient facility (procedure)

Psychiatric diagnostic interview, examination, history, mental status and 
disposition (procedure)

Optokinetic nystagmus test, bidirectional, with recording (procedure)

Psychiatric diagnostic evaluation

Ophthalmological services: medical examination and evaluation, with initiation 
or continuation of diagnostic and treatment program; comprehensive, established 
patient, 1 or more visits

Treatment of speech, language, voice, communication, and/or auditory processing 
disorder; individual

Treatment of speech, language, voice, communication, and/or auditory processing 
disorder; group, 2 or more individuals

Treatment of swallowing dysfunction and/or oral function for feeding

Caloric vestibular test with recording, bilateral; bithermal (ie, one warm 
and one cool irrigation in each ear for a total of four irrigations)

Caloric vestibular test with recording, bilateral; monothermal (ie, one 
irrigation in each ear for a total of two irrigations)

Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric 
gaze fixation nystagmus, with recording, positional nystagmus test, minimum 
of 4 positions, with recording, optokinetic nystagmus test, bidirectional 
foveal and peripheral stimulation, with recording, and oscillating tracking 
test, with recording

Spontaneous nystagmus test, including gaze and fixation nystagmus, with 
recording

Positional nystagmus test, minimum of 4 positions, with recording

Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, 
with recording

Psychiatric diagnostic evaluation with medical services

Oscillating tracking test, with recording

Use of vertical electrodes (List separately in addition to code for primary 
procedure)

Computerized dynamic posturography

Tympanometry and reflex threshold measurements

Comprehensive audiometry threshold evaluation and speech recognition (92553 
and 92556 combined)

Tympanometry (impedance testing)

Acoustic reflex testing, threshold

Acoustic immittance testing, includes tympanometry (impedance testing), 
acoustic reflex threshold testing, and acoustic reflex decay testing

Auditory evoked potentials for evoked response audiometry and/or testing 
of the central nervous system; comprehensive

Distortion product evoked otoacoustic emissions; comprehensive diagnostic 
evaluation (quantitative analysis of outer hair cell function by cochlear 
mapping, minimum of 12 frequencies), with interpretation and report

Psychotherapy, 30 minutes with patient and/or family member

Evaluation of auditory rehabilitation status; first hour

Neurobehavioral status exam (clinical assessment of thinking, reasoning 
and judgment, eg, acquired knowledge, attention, language, memory, planning 
and problem solving, and visual spatial abilities), per hour of the psychologist's 
or physician's time, both face-to-face time with the patient and time interpreting 
test results and preparing the report

Health and behavior assessment (eg, health-focused clinical interview, 
behavioral observations, psychophysiological monitoring, health-oriented 
questionnaires), each 15 minutes face-to-face with the patient; initial 
assessment

Health and behavior assessment (eg, health-focused clinical interview, 
behavioral observations, psychophysiological monitoring, health-oriented 
questionnaires), each 15 minutes face-to-face with the patient; re-assessment

Health and behavior intervention, each 15 minutes, face-to-face; individual

Physical therapy evaluation

Physical therapy re-evaluation

Occupational therapy evaluation

Occupational therapy re-evaluation

Development of cognitive skills to improve attention, memory, problem solving 
(includes compensatory training), direct (one-on-one) patient contact, 
each 15 minutes

Psychotherapy, 45 minutes with patient and/or family member

Medical nutrition therapy; initial assessment and intervention, individual, 
face-to-face with the patient, each 15 minutes

Medical nutrition therapy; re-assessment and intervention, individual, 
face-to-face with the patient, each 15 minutes

Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes

Education and training for patient self-management by a qualified, nonphysician 
health care professional using a standardized curriculum, face-to-face 
with the patient (could include caregiver/family) each 30 minutes; individual 
patient

Education and training for patient self-management by a qualified, nonphysician 
health care professional using a standardized curriculum, face-to-face 
with the patient (could include caregiver/family) each 30 minutes; 2-4 
patients

Education and training for patient self-management by a qualified, nonphysician 
health care professional using a standardized curriculum, face-to-face 
with the patient (could include caregiver/family) each 30 minutes; 5-8 
patients

Office or other outpatient visit for the evaluation and management of a 
new patient, which requires these 3 key components: A problem focused history; 
A problem focused examination; Straightforward medical decision making. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are self limited or minor. Typically, 10 minutes 
are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a 
new patient, which requires these 3 key components: An expanded problem 
focused history; An expanded problem focused examination; Straightforward 
medical decision making. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are of low to 
moderate severity. Typically, 20 minutes are spent face-to-face with the 
patient and/or family.

Office or other outpatient visit for the evaluation and management of a 
new patient, which requires these 3 key components: A detailed history; 
A detailed examination; Medical decision making of low complexity. Counseling 
and/or coordination of care with other physicians, other qualified health 
care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate severity. Typically, 30 minutes are 
spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a 
new patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; Medical decision making of moderate complexity. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are of moderate to high severity. Typically, 
45 minutes are spent face-to-face with the patient and/or family.

Psychotherapy, 60 minutes with patient and/or family member

Office or other outpatient visit for the evaluation and management of a 
new patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; Medical decision making of high complexity. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are of moderate to high severity. Typically, 
60 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
A problem focused history; A problem focused examination; Straightforward 
medical decision making. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are self limited 
or minor. Typically, 10 minutes are spent face-to-face with the patient 
and/or family.

Office or other outpatient visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
An expanded problem focused history; An expanded problem focused examination; 
Medical decision making of low complexity. Counseling and coordination 
of care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) 
are of low to moderate severity. Typically, 15 minutes are spent face-to-face 
with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
A detailed history; A detailed examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are of moderate 
to high severity. Typically, 25 minutes are spent face-to-face with the 
patient and/or family.

Office or other outpatient visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
A comprehensive history; A comprehensive examination; Medical decision 
making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies 
are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are of moderate 
to high severity. Typically, 40 minutes are spent face-to-face with the 
patient and/or family.

Domiciliary or rest home visit for the evaluation and management of a new 
patient, which requires these 3 key components: A problem focused history; 
A problem focused examination; and Straightforward medical decision making. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are of low severity. Typically, 20 minutes are 
spent with the patient and/or family or caregiver.

Domiciliary or rest home visit for the evaluation and management of a new 
patient, which requires these 3 key components: An expanded problem focused 
history; An expanded problem focused examination; and Medical decision 
making of low complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are of moderate 
severity. Typically, 30 minutes are spent with the patient and/or family 
or caregiver.

Domiciliary or rest home visit for the evaluation and management of a new 
patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health 
care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. Typically, 45 minutes 
are spent with the patient and/or family or caregiver.

Domiciliary or rest home visit for the evaluation and management of a new 
patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; and Medical decision making of moderate complexity. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are of high severity. Typically, 60 minutes are 
spent with the patient and/or family or caregiver.

Domiciliary or rest home visit for the evaluation and management of a new 
patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; and Medical decision making of high complexity. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the patient is unstable or has developed a significant new problem requiring 
immediate physician attention. Typically, 75 minutes are spent with the 
patient and/or family or caregiver.

Psychotherapy for crisis; first 60 minutes

Domiciliary or rest home visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
A problem focused interval history; A problem focused examination; Straightforward 
medical decision making. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are self-limited 
or minor. Typically, 15 minutes are spent with the patient and/or family 
or caregiver.

Domiciliary or rest home visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
An expanded problem focused interval history; An expanded problem focused 
examination; Medical decision making of low complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of low to moderate severity. Typically, 25 minutes are spent 
with the patient and/or family or caregiver.

Domiciliary or rest home visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: 
A detailed interval history; A detailed examination; Medical decision making 
of moderate complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are of moderate 
to high severity. Typically, 40 minutes are spent with the patient and/or 
family or caregiver.

Domiciliary or rest home visit for the evaluation and management of an 
Typically, 60 minutes are spent with the patient and/or family or caregiver.
established patient, which requires at least 2 of these 3 key components: 
A comprehensive interval history; A comprehensive examination; Medical 
decision making of moderate to high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) 
are of moderate to high severity. The patient may be unstable or may have 
developed a significant new problem requiring immediate physician attention. 

Home visit for the evaluation and management of a new patient, which requires 
these 3 key components: A problem focused history; A problem focused examination; 
and Straightforward medical decision making. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) 
are of low severity. Typically, 20 minutes are spent face-to-face with 
the patient and/or family.

Home visit for the evaluation and management of a new patient, which requires 
these 3 key components: An expanded problem focused history; An expanded 
problem focused examination; and Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are of moderate severity. Typically, 30 minutes 
are spent face-to-face with the patient and/or family.

Home visit for the evaluation and management of a new patient, which requires 
these 3 key components: A detailed history; A detailed examination; and 
Medical decision making of moderate complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) 
are of moderate to high severity. Typically, 45 minutes are spent face-to-face 
with the patient and/or family.

Home visit for the evaluation and management of a new patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; 
and Medical decision making of moderate complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) 
are of high severity. Typically, 60 minutes are spent face-to-face with 
the patient and/or family.

Home visit for the evaluation and management of a new patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; 
and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the patient is unstable or 
has developed a significant new problem requiring immediate physician attention. 
Typically, 75 minutes are spent face-to-face with the patient and/or family.

Home visit for the evaluation and management of an established patient, 
which requires at least 2 of these 3 key components: A problem focused 
interval history; A problem focused examination; Straightforward medical 
decision making. Counseling and/or coordination of care with other physicians, 
other qualified health care professionals, or agencies are provided consistent 
with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are self limited or minor. Typically, 
15 minutes are spent face-to-face with the patient and/or family.

Ophthalmological services: medical examination and evaluation with initiation 
of diagnostic and treatment program; intermediate, new patient

Home visit for the evaluation and management of an established patient, 
which requires at least 2 of these 3 key components: An expanded problem 
focused interval history; An expanded problem focused examination; Medical 
decision making of low complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies 
are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the presenting problem(s) are of low to 
moderate severity. Typically, 25 minutes are spent face-to-face with the 
patient and/or family.

Home visit for the evaluation and management of an established patient, 
which requires at least 2 of these 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of moderate complexity. 
Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, 
the presenting problem(s) are moderate to high severity. Typically, 40 
minutes are spent face-to-face with the patient and/or family.

Home visit for the evaluation and management of an established patient, 
face-to-face with the patient and/or family.
which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate 
to high complexity. Counseling and/or coordination of care with other physicians, 
other qualified health care professionals, or agencies are provided consistent 
with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of moderate to high severity. The 
patient may be unstable or may have developed a significant new problem 
requiring immediate physician attention. Typically, 60 minutes are spent 

Initial comprehensive preventive medicine evaluation and management of 
an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and 
the ordering of laboratory/diagnostic procedures, new patient; 18-39 years

Initial comprehensive preventive medicine evaluation and management of 
an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and 
the ordering of laboratory/diagnostic procedures, new patient; 40-64 years

Initial comprehensive preventive medicine evaluation and management of 
an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and 
the ordering of laboratory/diagnostic procedures, new patient; 65 years 
and older

Periodic comprehensive preventive medicine reevaluation and management 
of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and 
the ordering of laboratory/diagnostic procedures, established patient; 
18-39 years

Periodic comprehensive preventive medicine reevaluation and management 
of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and 
the ordering of laboratory/diagnostic procedures, established patient; 
40-64 years

Periodic comprehensive preventive medicine reevaluation and management 
of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and 
the ordering of laboratory/diagnostic procedures, established patient; 
65 years and older

Transitional Care Management Services with the following required elements: 
Communication (direct contact, telephone, electronic) with the patient 
and/or caregiver within 2 business days of discharge Medical decision making 
of at least moderate complexity during the service period Face-to-face 
visit, within 14 calendar days of discharge

Ophthalmological services: medical examination and evaluation with initiation 
of diagnostic and treatment program; comprehensive, new patient, 1 or more 
visits

Transitional Care Management Services with the following required elements: 
Communication (direct contact, telephone, electronic) with the patient 
and/or caregiver within 2 business days of discharge Medical decision making 
of high complexity during the service period Face-to-face visit, within 
7 calendar days of discharge

Ophthalmological services: medical examination and evaluation, with initiation 
or continuation of diagnostic and treatment program; intermediate, established 
patient

Cervical or vaginal cancer screening; pelvic and clinical breast examination

Diabetes outpatient self-management training services, individual, per 
30 minutes

Medical nutrition therapy; reassessment and subsequent intervention(s) 
following second referral in same year for change in diagnosis, medical 
condition or treatment regimen (including additional hours needed for renal 
disease), individual, face to face with the patient, each 15 minutes

Initial preventive physical examination; face-to-face visit, services limited 
to new beneficiary during the first 12 months of medicare enrollment

Annual wellness visit; includes a personalized prevention plan of service 
(pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service 
(pps), subsequent visit