NOV 04, 2021
Level of E/M documentation
A patient has stable primary open angle and nuclear cataracts, and the plan is to continue glaucoma meds and observe cataracts. What level of E/M does documentation support?It’s a level 4 E/M which is either 99204 or 99214. Both codes require medically appropriate history and/or exams and moderate level of medical decision making as shown on the chart below.
| Component |
Criteria |
Level |
| Number and/or complexity of problems: |
Two or more stable chronic illnesses |
Moderate |
| Risk of complications and/or morbidity: |
Prescription drug management |
Moderate |