So, you say you have the documentation for a level 4? So I'll assume <I hate to do that> you have documented a detailed history and detailed examination, right?
So for your MDM...
I'll assume this is a new problem (correct me if I'm wrong please...)
some people might say WITH work up...some people might say WITHOUT work up...but you'll see it won't even matter...
1 point Lab
1 point CXRY
Respiratory therapy...did the pt receive breathing treatments? if they did, that would fall under tx options on the table of risk. However, the RX you have qualifies for higher risk ... of moderate
Either way if there was or wasn't work up... you come up with a MODERATE complexity... which if the history and exam was appropriately documented, justifies a 99284.
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