For your first example, I would code 99204. Even if you were to level risk at 5 due to patient risk factors, you would also need to get a level 5 for either number/complexity of problems or data.
Let's first look at data (this is to me the most black & white of the elements). To meet extensive, besides the 3 of category 1, you need to have either Category 2 independent interpretation of tests or Category 3 discussion with external physician/health care professional. Unless your physician not just read the CT report, but reviewed the images and independently interpreted (which is clearly not documented), you don't have Category 2. Same for Category 3 - no documentation of discussion with external health care professional.
You have: review of CT report, review of hospital records, independent historian. I will note the documentation of independent historian could be clearer, but I follow the dots. Three requirements of Category 1. So level 4 data.
Number/complexity of problems. To meet high, you must have either 1 or more chronic illness with severe exacerbation, progression or side effects OR 1 acute or chronic illness or injury that poses a threat to life or bodily function. Without active appendicitis, and asymptomatic gallstones, I don't see level 5. Multiple acute illnesses (even with complication) does not get you to level 5. At this point, whether you count number/complexity of problems as a 3 or 4 is a moot point. It's not 5.
Problems: level 3 or 4
Data: level 4
Risk: level 4 or 5
Whether each of those "OR" in problems and risk go either way, it doesn't matter. You could spend another 15 minutes trying to decide either way and it would simply not make any difference in your final level selection. You are at level 4.
