Level IV: General Comments

 Urgent Urgent Tx of condition of condition 

 Multiple diagnostic studies 

 Special studies alone (CT, MRI,US) 

 ED Interventions: 

 Nebs 21 

 Parenteral Parenteral medications medications 

 Usually not admitted 

Level V: General Comments 

 Many Admissions Frequently Involve: 

 Prolonged services in ED 

 Special Studies with other tests Special Studies with other tests-(CT/MRI/US) (CT/MRI/US) 

 Multiple reassessments 

 Interpretations of EKG or x Interpretations of EKG or x-rays 

 Old record review 

 Documented conversations

History 

The history portion of a patient The history history portion portion of a patient s patient s’ chart includes some or all of the following elements: 

Risk

 The third part of the overall Medical decision The third part of the overall overall Medical Medical decision decision Making 

 The Risk Table is an official part of CMS Documentation Guidelines 

 Is scored independently 

 Along with Management Options and Amount and  Complexity of Data 

 Highest level of risk in any category determines the overall risk score

Nature of Presenting Problem

 99281 Usually, the presenting problems are self limited or minor 

 99282 Usually, the presenting problem(s) are of problem(s) are of low to moderate to moderate  severity 

 99283 Usually, the presenting problem(s) are of problem(s) are of moderate severity moderate severity.

 99284 Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not by the physician physician but do not pose an immediate significant threat to life or physiologic function. 

 99285 Usually, the presenting problem(s) are of high severity and pose an immediate 18 are of high severity and pose an immediate immediate significant threat to life of physiologic function.