What CPT codes are used for acute sick visits?

Use standard E/M codes: 99202-99205 for new patients, 99212-99215 for established patients, based on medical decision-making complexity. Most acute visits with straightforward diagnosis support 99213; multiple conditions or moderate complexity supports 99214. Document the number of problems addressed and complexity of decision-making to support code selection.

How do I document medical decision-making for acute visits?

Document: number and status of problems addressed (acute self-limited, acute uncomplicated, acute illness with systemic symptoms), data reviewed (tests ordered or reviewed), and risk of complications or morbidity. For acute visits: one self-limited problem = straightforward (99212), acute uncomplicated = low (99213), acute illness with systemic symptoms = moderate (99214).

When should diagnostic testing be documented for acute visits?

Document: clinical indication for testing, pre-test probability, results if available, and how results affect management. Point-of-care tests (rapid strep, flu, urinalysis) require documented medical necessity. Include interpretation and plan changes based on results. Unnecessary testing may not be reimbursed and exposes patients to unnecessary intervention.

What documentation supports antibiotic prescribing decisions?

Document: clinical findings supporting bacterial vs viral etiology, diagnostic testing results if obtained, risk stratification, and rationale for prescribing or not prescribing antibiotics. For conditions with guidelines (strep pharyngitis, UTI, sinusitis), document criteria met. This supports appropriate use and addresses antibiotic stewardship quality measures.

How should return precautions be documented for acute visits?

Document: specific warning signs discussed with patient, expected improvement timeline, when to return to office, when to go to ED, and that patient verbalized understanding of return precautions. This demonstrates patient education, supports medical necessity for follow-up if needed, and provides liability protection.

Acute Sick Visit Template - Primary Care Documentation

Primary Care — Acute Sick Visit Template

Primary Care Family Medicine Updated: 11/7/2025

The Acute Sick Visit Template is designed for primary care providers managing same-day or urgent care visits for acute complaints such as upper respiratory infections, urinary tract infections, acute injuries, and other non-emergent conditions. This focused template efficiently documents the chief complaint, focused history of present illness, targeted review of systems, focused physical examination, assessment, and treatment plan for acute conditions. The template supports appropriate billing for acute care visits (CPT 99212-99215 for established patients, 99202-99205 for new patients) while ensuring thorough documentation of medical decision-making. Key sections include symptom onset and duration, associated symptoms, severity assessment, relevant past medical history affecting treatment, focused physical examination findings, diagnostic considerations, treatment plan with medications or procedures, patient education on symptom management and warning signs, and follow-up instructions. This template streamlines documentation for high-volume acute care visits while maintaining quality and compliance. Ideal for primary care clinics, urgent care centers, walk-in clinics, and family medicine practices managing acute patient complaints.

Chief Complaint

{Patient's primary complaint in their words}

History of Present Illness

Onset, duration, location, quality, severity (0-10 scale), aggravating/alleviating factors, associated symptoms, prior treatments tried, impact on daily activities.

Review of Systems (Focused)

Relevant systems based on chief complaint. Constitutional, HEENT, CV, Resp, GI, GU, MSK, Skin, Neuro as indicated.

Past Medical History (Relevant)

Chronic conditions affecting current complaint, medications, allergies.

Physical Examination (Focused)

Vitals: BP, HR, RR, Temp, SpO2.
Focused exam relevant to chief complaint: HEENT, Neck, CV, Resp, Abdomen, GU, MSK, Skin, Neuro as indicated.

Assessment & Plan

1) Primary diagnosis — clinical reasoning, differential considered.

Treatment: medications, procedures, referrals.
Patient education: symptom management, warning signs, when to return.
Follow-up: return if not improved in X days, or sooner if [specific warning signs].

Patient Instructions

Written instructions provided. Return precautions discussed. Patient verbalized understanding.

Primary Care — Acute Sick Visit Template

Template