1. Level 5 Template
2. Coding Breakdown
3. General Thoughts

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Level 5 Template

Medical Decision Making

Complexity (and number) of Problems Addressed: High.
– Complaint that could pose threat to life or bodily function addressed: Chest Pain
Emergent differential diagnoses considered but not limited to:
ACS, Pneumothorax, Pulmonary Embolus, Tamponade, Aortic Dissection.
Given history, exam, workup presentation not overtly consistent with above diagnoses.
Last Stress Test:  never
Last Heart Catheterization:  never
HEART Score: 4

Amount and/or complexity of Data to be reviewed/analyzed: Extensive
– Category 1: Tests and documents: 3 or more unique tests ordered
– Category 2: Independent interpretation of tests: YES. Chest X-Ray

Risk of complications and/or Morbidity or Mortality of Patient Management: High
– Decision regarding hospitalization: Admit

Overall Visit Complexity: High

DATA REVIEW:
** If 3 labs not ordered:
– Category 1: Review of prior external notes as documented above
– Category 1: Assessment requiring Independent Historian: due to patient’s altered mental status case discussed with [***]
** If no independent interpretation performed:
– Category 3: Qualified Healthcare Professional Discussion of management or test interpretation: YES.

RISK:
**High Risk Not Admitted
– Parenteral controlled substances administered in ED.
– Medications/Drug Therapy provided requiring monitoring for toxicity.

**Moderate Risk
– Diagnosis/Treatment limited by social determinants of health: homelessness
– Prescription Drug Management:

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Coding Breakdown

• High CPT Coding [99223, 99285, 99233, 99236]
  • Coding based on highest 2 of 3 sections [COPA, Data Review, Risk]
  • Data Review requires 2 of 3 categories to be fulfilled

Number & Complexity of Problems Addressed
* 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
OR
* 1 acute or chronic illness that poses a threat to life or bodily function

Amount and/or Complexity of Data to be Reviewed/Analyzed
(Each unique test, order or document contributes to the combination of 2 or combination of 3 in Category 1 below)

• Tests, documents [external notes], or independent historian
• Independent interpretation of tests like CXR
• Discussion of management or test interpretation with external physician/other qualified health care professional

Risk of Complications and/or Morbidity or Mortality of Patient Management
LEVEL 5 High risk of morbidity from additional diagnostic testing or treatment
Examples only:
* Drug therapy requiring intensive monitoring for toxicity
* Decision regarding elective major surgery with identified patient or procedure risk factors
* Decision regarding emergency major surgery
* Decision regarding hospitalization or escalation of hospital level of care
* Decision not to resuscitate or to de-escalate care because of poor prognosis
* Parenteral controlled substances

LEVEL 4 Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
* Prescription Drug Management
* Decision regarding minor surgery with identified patient or procedure risk factors
* Decision regarding elective major surgery without identified patient or procedure risk factors
* Diagnosis or treatment significantly limited by social determinants of health

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General Thoughts

• HPI and Physical exam technically don’t matter
• ROS is no longer needed
• COPA
  • Other than medico-legal reasons the only reason to type much of anything is because COPA is vague and somewhat up to Billing team’s discretion and may vary chart to chart. The more dangerous a provider makes a problem sound the more likely they are to capture a higher billing level in the COPA category
  • This section is currently very vague, there’s no published guide as to what problems or really complaints addressed are considered high risk. Abdominal pain for instance is up to biller’s discretion if it “sounds severe”.
• Data Review
  • This area is pretty easy for any sick patient.
    • Of note many workups that go home like a severe abdominal pain that turns out to be kidney stone going home after IV toradol and CT, if you don’t interpret the imaging yourself you may have missed out on a higher coding opportunity for the work you did.
  • Category 1: Pull in 3 labs into your note and it suffices without interpreting them at all
  • Category 2: “Independently review” an X-ray and you’ve fulfilled this category, and you allow yourself to profit from your ECG read for instance because if you only interpret an ECG the billing team cannot double dip and use it for Level of Acuity decisions as well as RVU billing.
  • Category 3: Anytime you document talking to another doctor for admission, consultation etc this is fulfilled.
• Risk:
  • In short:
    • did you give Opiates IV/IM?
    • did you give a medication that requires monitoring for toxicity [i.e. IV beta blocker, propofol, etc]?
    • did you admit the patient?
  • not much else you can do here

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