Level 3 Chart
Suggested E/M Coding Level: 3, 99283
This level has been selected based on the 2023 CPT guidelines for E/M codes in the Emergency Department based on 2/3 of the following.
- COPA:
- This patient has the following 2 or more self-limited or minor problems: []
OR
- This patient has the following stable chronic illness: []
OR
- This patient has the following acute uncomplicated injury: []
- Data(1/2 categories following were performed):
- I reviewed or ordered at least two unique tests or external notes as following: []
OR
- The assessment required the following independent historian: []
- Risk:
- This patient has a low risk of morbidity due to further diagnostic testing or treatment
- Last updated January 21, 2023
Charting Tips
- This note is intended to be placed at the end of your chart to facilitate coders in selecting the correct E/M level for the visit.
- If you bill greater than 30 minutes of critical care time this note is no longer necessary because an E/M level is not billed with critical care time
- It may be 15 extra seconds to dictate the disease in exacerbation or specify that you reviewed hospitalist records and two labs but that may be the difference between coding as a 3 instead of a 2.
- Remember you only have to meet “low” MDM for 2/3 sections so you can delete the unnecessary section.
- There really isn’t much given by CMS as far as what constitutes “low” risk MDM other than low “low risk of morbidity from additional testing or treatment.”