esTABLIsHeD PATIenT LeveL-Iv (99214) vIsIT worksHeeT
Think level IV if you do any of the following at a patient visit: • See a new problem with uncertain prognosis (e.g., lump in breast); • See a complicated injury (e.g., fall with loss of consciousness); • Spend more than 25 minutes with a patient.
To confirm that it’s a level-IV visit, check the requirements below.
Your documentation must have two of the following three elements.
1. HISTORY: Include all of the following: l   HISTORY OF PRESENT ILLNESS: Four elements (location, quality, severity, duration, timing, context, modifying factors or associated symptoms) or the status of at least three chronic conditions l  PAST HISTORY: One item (medical, family or social – e.g., non-smoker) 2. EXAM: Include five organ systems.
l  Examination of affected body area and at least four other symptomatic-related organ systems 3. MEDICAL DECISION MAKING: Meet the requirements for at least two of the following: • New problem, additional work-up planned = 4 points • New problem, no work-up planned = 3 points • Established problem, worsening = 2 points • Established problem, stable = 1 point • Independent review of X-ray, ECG or blood work = 2 points • Order or review procedural test (e.g., ECG, spirometry or EGD) = 1 point • Review and summarize old records or discuss case with another provider = 2 points l  RISK: One of the following required • One chronic illness with mild exacerbation • Previously undiagnosed new problem of uncertain prognosis (e.g., breast lump or chest pain) • Acute complicated injury (e.g., head injury with loss of consciousness) TIME-BASED BILLING
The visit must meet the following requirements:
l  Total visit time: 25 minutes or more
l  Counseling time: More than half of the total visit time
LeveL-Iv esTABLIsHeD PATIenT exAmPLes
The six documented cases below qualify as level-IV visits. The two key qualifying components are noted in parentheses at the top of each case. As you’ll see, it’s not the length of the documentation but the content that is important.
(HPI and new problem/X-ray)
(HPI and new problem/uncertain prognosis)
CC: Ankle pain
CC: Chest pain
HPI: 35-year-old male with sharp pain in left ankle. It began
HPI: 58-year-old female with intermittent, sharp chest pain
two weeks ago and has gotten worse in the past three days.
over two weeks. Episodes last 10 minutes at a time. Pain PH: Left ankle injury due to football in 1999.
ROS: No neurological symptoms. No rashes.
PH: Non-smoker, no family history of cardiovascular
EXAM: Pain with palpation over medial malleolus. No
bruising. Range of motion good but produces pain. Neuro
ROS: No shortness of breath. No reflux.
EXAM: Vitals: BP 120/80, P 65
DATA: Ankle X-ray ordered. I reviewed results personally and
found no signs of fracture or dislocation.
A/P: Left ankle pain, likely strain or tendonitis. Referred to
A/P: Chest pain. ECG and stress test ordered. Follow up
sports medicine department to evaluate and treat.
(HPI and exam)
(HPI and chronic illness mild exacerbation/testing)
CC: Cough
CC: Shortness of breath
HPI: 75-year-old male with productive cough for five days,
HPI: 60-year-old female with emphysema and increased
worse at night. Patient also has fever and chest pain. Patient shortness of breath over past five days. She uses albuterol using cough syrup without improvement.
and ipratropium three to four times per day, which helps. PH: Non-smoker.
ROS: Denies shortness of breath or heart palpitations.
PH: Former smoker.
EXAM: Vitals: temp 101.5, BP 140/80
ROS: Denies chest pain or fever.
EXAM: Vitals WNL
Chest: rhonchi bibasilar, pain on deep inspiration A/P: Emphysema with mild exacerbation. Requested chest
X-ray, electrocardiogram and complete blood count. Will
A/P: Acute bronchitis. Rx: Azithromycin, expectorant. Follow
up as needed.
(Three chronic, stable illnesses)
CC: Depression
CC: Follow-up on medical problems
HPI: 53-year-old male with depression and some anxiety
HPI: 63-year-old male with hypertension. Blood pressure
issues. Denies suicidal ideations. Has taken alprazolam in has been controlled. Denies headache. His emphysema is stable, but he does get mildly short of breath with activity. EXAM: Vitals: BP 120/80, P 63
His hypothyroidism is now stable. Recent thyroid stimulating hormone testing was normal.
PH: Not smoking.
A/P: Depression. Had long discussion with patient and
counseled him on exacerbating factors and treatment
ROS: Noted above.
EXAM: Vitals: BP 138/78
Total visit time 25 minutes, counseling time 15 minutes.
Chest: Clear to auscultation
CV: Regular rhythm and rate
A/P: Hypertension, stable, continue meds.
Emphysema, stable, continue meds.
Hypothyroidism, stable, continue meds.
Developed by Thomas A. Waller, MD, Mayo Clinic Department of Family Medicine, Jacksonville, Fla. Copyright 2006 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. “Coding Level-IV Visits Without Fear.” Waller TA. Fam Pract Manag. February 2006:34-38,


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