# ER E/M level of care charges



## tuffy1 (Mar 11, 2009)

I have a patient that comes into the ER with a CC of a cough or difficulty breathing.  The patient is either in the teen or elderly.  This is for the physician's charge.  Have the documentation for a Level 4 charge and the patient had 2 things done: (x-ray and resp. therapy or lab and x-ray).  The final dx. is acute bronchitis.  What level would you charge a level 4 or a level 3?  Also a prescription is also given to the patient.


----------



## ARCPC9491 (Mar 11, 2009)

So, you say you have the documentation for a level 4? So I'll assume <I hate to do that> you have documented a detailed history and detailed examination, right? 

So for your MDM...

I'll assume this is a new problem (correct me if I'm wrong please...)
some people might say WITH work up...some people might say WITHOUT work up...but you'll see it won't even matter...

1 point Lab
1 point CXRY

Respiratory therapy...did the pt receive breathing treatments? if they did, that would fall under tx options on the table of risk. However, the RX you have qualifies for higher risk ... of moderate  

Either way if there was or wasn't work up... you come up with a MODERATE complexity... which if the history and exam was appropriately documented, justifies a 99284.


----------



## tuffy1 (Mar 11, 2009)

Yes on the detail history and yes this is a new problem.  Thank you for you help.


----------

