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Level 4 Chart

General Level 4

Suggested E/M Coding Level: 4, 99284

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 CoPA, Data, and Risk.

  • COPA:
    •  The patient has an exacerbation, progression, or side effect of treatment of the following illness/illnesses: []

                            OR

    • The patient has the following 2 or more chronic but stable illnesses: []

                            OR

    • The patient has the following undiagnosed illness with uncertain prognosis: []

                            OR

    • The patient has the following acute illness with systemic symptoms: []

                            OR


    • The patient has the following acute complicated injury: []
 
  • Data(1/3 categories were performed):
    • I reviewed or ordered at least three unique tests, external notes, and/or the history required an independent historian as one of the three requirements as following: []

                             OR

    • I independently interpreted the following test: []

                             OR


    • I discussed the management of the patient with the following external physician or qualified healthcare provider: []
 
  • Risk:
    • This patient has a moderate risk of morbidity as evidenced by the following further diagnostic testing or treatment actions: []

Level 4 - Exacerbation/Progression, Labs/Rads

Suggested E/M Coding Level: 4, 99284

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 CoPA, Data, and Risk.

  • COPA:
    •  The patient has an exacerbation, progression, or side effect of treatment of the following illness/illnesses: []
  • Data(1/3 categories were performed):
    • I reviewed or ordered at least three unique tests, external notes reviewed, and/or the history required an independent historian as one of the three requirements as following: at least 3 labs/imaging studies were obtained and/or reviewed
  •  

Level 4 - Exacerbation/Progression, Rx Drug Management

Suggested E/M Coding Level: 4, 99284

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 CoPA, Data, and Risk.

  • COPA:
    •  The patient has an exacerbation, progression, or side effect of treatment of the following illness/illnesses: [] 
  • Risk:
    • This patient has a moderate risk of morbidity as evidenced by the following further diagnostic testing or treatment actions: Prescription drug management

Level 4 - Acute illness, Rx Drug Management

Suggested E/M Coding Level: 4, 99284

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 CoPA, Data, and Risk.

  • COPA:
    •  The patient has an acute illness with systemic symptoms: [] 
  • Risk:
    • This patient has a moderate risk of morbidity as evidenced by the following further diagnostic testing or treatment actions: Prescription drug management
  • 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 4 instead of a 3.
  • Remember you only have to meet “moderate” MDM for 2/3 sections so you can delete the unnecessary section.
  • Refer to the 2023 Guidelines table for examples of situations to suggest moderate risk.