Level 5 Chart
General Level 5
Suggested E/M Coding Level: 5, 99285
This 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 a severe exacerbation, progression, or side effect of treatment of the following illness/illnesses: []
OR
- The patient has the following acute or chronic illness/injury that poses a possible threat to life or bodily function: []
- Data(2/3 categories following 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: []
AND
- 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 high risk of morbidity due to further diagnostic testing or treatment. Rationale: []
Admit Level 5 - Labs/Rads, Hospitalist Consult, Admit
Suggested E/M Coding Level: 5, 99285
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.
- Data(2/3 categories following 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: At least 3 labs/imaging studies were obtained and/or reviewed.
AND
- I discussed the management of the patient with the following external physician or qualified healthcare provider: Admitting physician/hospitalist
- Risk:
- This patient has a high risk of morbidity due to further diagnostic testing or treatment. Rationale: Decision made regarding admission
Obs Level 5 - Labs/Rads, EKG Interp, Obs Admit
Suggested E/M Coding Level: 5, 99285
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.
- Data(2/3 categories following 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: At least 3 labs/imaging studies were obtained and/or reviewed
AND
- I independently interpreted the following test: EKG interpretation
- Risk:
- This patient has a high risk of morbidity due to further diagnostic testing or treatment. Rationale: Consideration given to hospital admission, placing in Observation Unit
- Last updated February 2, 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 5 instead of a 4.
- Remember you only have to meet “high” MDM for 2/3 sections so you can delete the unnecessary section.
- Refer to the 2023 Guidelines table for examples of situations to suggest high risk.
- Included below the general note are some more common situations that are pre-filled. Make sure to check them for accuracy.