Coding and billing

Level 5 requirements

HPI: 4 modifiers

ROS: 10 Systems

Social History: 1 fact

PEx: 8 systems

MDM: high complexity

Examples of a level 5 admission:

1. Appendicitis to OR

2. ACS or chest pain

3. pneumonia and comorbidity

4. CVA

5. Asthma Exacerbation admitted

6. COPD exacerbation with bronchitis

Level 4 requirements

HPI: 4 modifiers

ROS: 2 systems

PEx: 5 systems or 1 in detail

MDM: moderate complexity

Examples of a level 4 visit:

1. Cellulitis admission with no co-morbidity

2. Asthma Exacerbation discharged

3. Pyelonephritis discharged

Level 3 Requirements

HPI: 1 modifier

ROS: 1 system

PEx: 2 systems

MDM: low complexity

Examples of a level 3 visit:

1. Ankle sprain with negative x-ray

(if prescription meds are given, this can sometimes be a 4)

2. Pharyngitis