• 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