Final Code Level

Date of Service : 04-08-2024

Type of Service : Office/Outpatient visit
Type of Visit : New Patient
Service Provided : --
Option Service : --

Diagnosis Codes (per documentation )

Level of Documentation As Reviewed by Coder / Auditor

History --
Physical Examination --
Number and Complexity of Problems Addressed moderate
Amount and/or Complexity of Data to be Reviewed and Analyzed Limited
Risk of Complications and/or Morbidity or Mortality of Patient Management moderate
Medical Decision Making MODERATE COMPLEXITY
Total Face-to-Face Time --
Total Time Of Critical Care Service Provided --

Reviewer’s Code : 99204

Examination --

Medical Decision Making MODERATE COMPLEXITY

Number and Complexity of Problems Addressed : MODERATE

1 Self-limited or minor problem : 0

2 or more self-limited or minor problems : 0
1 Stable chronic illness : 0
1 Acute, uncomplicated illness or injury : 0
1 Stable, acute illness : 0
1 Acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care : 0
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment : 0
2 or more stable chronic illnesses : 1
1 Undiagnosed new problem with uncertain prognosis : 0
1 Acute illness with systemic symptoms : 0
1 Acute complicated injury : 0
1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment : 0

EM Calculator Report 137138 Details

 1 Acute or chronic illness or injury that poses a threat to life or bodily function : 0

Amount and/or Complexity of Data to be Reviewed and Analyzed : 3

Ordering of each unique test : 1

Review of prior external note(s) from each unique source : 0
Review of the result(s) of each unique test : 1
Minimal or None : 1
Assessment requiring an independent historian(s) : 0
Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported) : 0
Discussion of management or test interpretation with external physician/other qualified health care
professional/appropriate source
(not separately reported) : 0

Risk of Complications and/or Morbidity or Mortality of Patient Management : MODERATE

Rest : 0
Gargles : 0
Elastic bandages : 0
Superficial dressings : 0
Other minimal risk testing or treatment : 0
Minor surgery with no identified risk factors : 0
Physical therapy : 0
Occupational therapy : 0
IV fluids without additives : 0
Other low risk testing or treatment : 0
Other moderate risk testing or treatment : 0
Diagnosis or treatment significantly limited by social determinants of health : 0
Decision regarding elective major surgery without identified patient or procedure risk factors : 0
Decision regarding minor surgery with identified patient or procedure risk factors : 0
Prescription drug management : 1
Decision not to resuscitate or to deescalate care because of poor prognosis : 0
Other high risk testing or treatment : 0
Parenteral controlled substances : 0
Decision regarding hospitalization or escalation of hospital level care : 0
Decision regarding emergency major surgery : 0
Decision regarding elective major surgery with identified patient or procedure risk factors : 0
Drug therapy requiring intensive monitoring for toxicity : 0

EM Calculator Report 137138 Details