level 5

Milwaukee WI
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Not Appendix C

Actually Appendix C just gives brief scenarios that would likely qualify for the various levels of service. This is not same as an example of documentation for a level 5 visit.

There will be a difference in the required documentation for a level 5 depending on whether this is a new patient vs an established patient.

I recommend you check www.emuniversity.com ... I haven't explored it well enough to tell if you he lists examples of the documentation for each level of service, but it would certainly be a good place to start.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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1995 Guidelines for level 99215

This would depend on your MAC, too, but here goes:

HPI = would need comprehensive level that includes 4 or more elements from location, timing, quality, context, severity, modifying factors, duration and associated signs and symptoms.

ROS = comprehensive with 10 or greater complete systems or with a statement that.."all other systems reviewed negative."

PFSH = complete 2 or 3 areas

Exam = comprehensive with 8 or more of 12 organ systems

MDM = High complexity with having to meet only 2 of each of the three elements of # of diagnosis, type of data, and risk of significant complications, etc.

Note that established only requires two of the three components of History, Exam, and MDM but all elements in the history (HPI, ROS, and PFSH) must be met.

New patients must meet all three components.

Time may be used and is the overriding factor in determining level of visit if over 50% of that time was spent in counseling and/or coordination of care as documented by the provider.

E/M university is a great tool and has a free coding course on it!!