Examples
Below you'll find sample level 3, 4, and 5 notes/evaluations with analysis and examples from the ACEP FAQ.
Level 3 Note
CC: Hives
Emergency Dept Physician Note History obtained from pt and mom - reliable historians CC: Hives/rash HPI: 4F with itchy rash that started yesterday. Had mango for the first time last night. No other exposures/meds/allegens. No airway sx. Eating/drinking well, no n/v/d, trouble breathing/swallowing, noisy breathing. Never had rash or allergies like this before. Physical Exam: 92/40 100 20 100%RA 98F Gen: Smiling, playful HEENT: No post pharynx swelling, tongue nl, no drooling, no stridor Resp: Lungs CTAB without wheeze CV: RRR, not tachy Skin: raised rash on arms, legs, chest, back, mildly excoriated, c/w hives Medical Decision-Making In summary, 4F with itchy rash after mango last night. Never had hives before. No aerodigestive sx, appears very well on exam. DDx: food allergy, idiopathic urticaria, early viral syndrome Plan: Rx for claritin, mom can use topical OTC steroid on particularly itchy areas, reassurance. Data Review & Summary Emergency Dept Course & Updates Final Disposition: Home Condition: Stable Diagnosis: urticaria food allergy
Analysis
Standard hives without any signs of anaphylaxis. There's nothing special about it, and I'm truly just following the guidelines as written. I'm not upcoding or downcoding. You'll also notice that I'm not documenting a huge MDM, nor am I calling out the individual elements as they're intuitive:
- Data: No testing, but since mom provided some history given the patient is 4 years-old, this is: Limited complexity, Level 3. Had I needed to review a prior allergy visit, or peds visit – and I'd reviewed 2 notes, it would have been a level 4.
- Risk: I did prescription drug management; I wrote an Rx for claritin and we discussed OTC steroid cream. IMO I don't think it needs to be called out, because it's clear from the record. Moderate risk, Level 4.
- Problem: This could be categorized as self-limited/minor, but reading the definitions, I think this is probably still "acute, uncomplicated illness." Since it's low but not no-risk of morbidity. I guess one could argue that a coder might want to know how you categorized this problem, so if needed that could be added to the MDM. Low complexity, Level 3. Note: even if this was Minimal (Level 2), it would not change the overall score.
Overall, this makes this a level 3 chart.
Level 4 Note
CC: Ankle Sprain
Emergency Dept Physician Note History obtained from pt - reliable historian CC: Ankle Sprain HPI: 26M prev healthy with ankle twisting today, rolled ankle stepping off curb ~2hr ago. Too painful to walk despite ice so came to the ER. Pain is lateral R ankle. No weakness/numbness/tingling. No other injuries/complaints. Physical Exam: 152/85 85 20 99%RA 98F Gen: Well-appearing in NAD R Ankle Exam: Appearance/Skin: Mild swelling to lat mall; no lac, abrasion, redness noted. Bones: + mild lat mall TTP; no medial mall TTP, base of 5th MT TTP or navicular TTP. Joint: Neg squeeze test, mild decr ROM ankle 2/2 pain. Other Joints: Knee and toes FROM nontender. No fibular head TTP. Neuro: Str/sens 5/5 in all tibial and fibular nerve distributions. Vascular: 2+ DP, CR less than 2s in all toes. Compartments: Soft. Gait: Limping, requires assistance to walk. Medical Decision-Making In summary, 26M with R ankle injury with mild lat mall swelling, tenderness. Neurovasc intact. DDx: sprain vs strain; fx Plan: Motrin and ice pack, XR. Data Review & Summary XR my read — no fx noted. Emergency Dept Course & Updates Pain better after motrin and ice pack. Will dc home with ankle double-strap for support, encourage motrin at home for next 3-5 days prn. Final Disposition: Home Condition: Improved Diagnosis: R ankle sprain
Analysis
This is a standard ankle sprain visit. There's nothing special about it, and I'm truly just following the guidelines as written. I'm not upcoding or downcoding. You'll also notice that I'm not documenting a huge MDM, nor am I calling out the individual elements as they're intuitive:
- Data: I ordered an XR and interepreted it myself. Moderate complexity, Level 4.
- Risk: I did prescription drug management; I gave motrin in the ER and told him to take motrin at home. Again, I don't think it needs to be called out, because it's clear from the record that I ordered motrin. Moderate risk, Level 4.
- Problem: This is an acute, uncomplicated injury. I guess one could argue that a coder might want to know how you categorized this problem, so if needed that could be added to the MDM. Low complexity, Level 3.
Overall, this makes this a level 4 chart.
Level 5 Note
CC: Pleuritic chest pain
Emergency Dept Physician Note History obtained from pt - reliable historian CC: CP HPI: 37F with no sig PMH pleuritic CP for the past 2 days with assoc upper back pain. Feeling mildly SOB today so came to the ER. COVID tested neg x3 at home. No f/c, no cough. Takes OCPs. No leg swelling, recent immob/trauma, prior PE/DVT, fam hx of VTE. CP is L sided, non-radiating. Never had pain like this before. Runs 3x a week, never gets CP/SOB. Denies other sx. Takes no other meds. Physical Exam: 152/85 110 20 95%RA 99F Gen: Well-appearing in NAD, speaking in full sentences Mental Status - alert, oriented x 3 Eves - pupils equal and reactive Throat - normal Neck - supple, no significant adenopathy Chest - clear to auscultation, no wheezes, rales or rhonchi, no tenderness to palpation Heart - tachy rate and reg rhythm, normal S1/S2 no m/r/g Abdomen - soft, nontender, nondistended, no masses or organomegaly Back exam - no CVA tenderness noted, no rash, no midline ttp Neurological - motor and sensory grossly normal bilaterally, normal gait Extremities - no clubbing, cyanosis or edema Skin - warm and dry Medical Decision-Making In summary,37F with new pleuritic CP x2d, now SOB as well. Here on exam is mildly tachycardic, very well appearing, exam without clear cause of her sx. DDx: PE, pleurisy; doubt pericarditis given no change w position; doubt ACS given it is pleuritic, will start w EKG. Plan: EKG, CXR, will get d-dimer given tachycardia/Wells Score, UPreg, basic labs. Toradol for pain for now. Data Review & Summary EKG my read - NSR @ 105 without ST/TW changes, no prior for comparison, no arrhythmia noted. CXR my read - No PTX, cardiomegaly, infiltrate, signs of failure. D-dimer elevated 0.51, will get CTA. CTA radiology read: No PE, no other cause of CP noted. Emergency Dept Course & Updates Pt better after toradol, no longer tachycardic . Likely pleurisy, will dc home w motrin for pain, strict return prec discussed. Final Disposition: Home Condition: Improved Diagnosis: Pleurisy
Analysis
Again — nothing special here:
- Data: I read the EKG and CXR myself, and I ordered a bunch of labs. High complexity, Level 5.
- Risk: I did prescription drug management; I gave toradol and prescribed it as an outpatient. Again, I don't think it needs to be called out, because it's clear from the record that I ordered motrin. Moderate risk, Level 4.
- Problem: This patient is tachycardic with pleuritic CP and SOB and is on OCPs. She certainly could have a PE which is life-threatening. Thankfully she didn't. But I did an extensive evaluation — EKG, labs, CXR, CT angio — to rule it out, and therefore this is high complexity. Again — I could see a coder wanting you to call this out since you're not admitting the person to the hospital perhaps. High risk, Level 5.
Overall, this makes this a level 5 chart.
ACEP Examples
Here are some rough examples from the ACEP FAQ.
Problem Complexity, from the ACEP FAQ:
In response to a reader’s question, CPT Assistant indicated that abdominal pain would likely represent “at least” Moderate COPA. This could be a patient with chronic abdominal pain, so the presentation would be considered a chronic illness with exacerbation. It may be a patient with no history of abdominal pain that would be an undiagnosed new problem with uncertain prognosis. Or it might present as abdominal pain with vomiting and diarrhea, so it would score as an acute illness with systemic symptoms.
This concept can be applied to many evaluations for patient complaints that should be considered at least Moderate COPA. The following are some examples, but this is not an all-inclusive list:
At least Moderate Problem Complexity:
- Abdominal pain
- Psychiatric complaints
- Back pain
- Shortness of breath
- Chest pain
- Systemic rash
- Diarrhea
- Vomiting
- Dizziness
- Weakness
- Headache, Neck pain
- Syncope
The final diagnosis for a condition, in and of itself, does not determine the complexity of the MDM. The presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, may indicate that an extensive evaluation is required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.
The following high COPA examples may be demonstrated by the totality of the medical record as demonstrated implicitly by the presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, or overall medical decision making, as demonstrated in the entire record.
This is not an all-inclusive list; high COPA should be considered for evaluations of patients with presentations potentially consistent with, but not limited to:
Likely High Problem Complexity*:
- Active labor
- Missed/incomplete abortion
- Ectopic pregnancy
- Ocular emergencies
- Acute intra-abdominal infection or inflammatory process
- Ovarian torsion
- Behavioral health decompensation
- Pulmonary embolism
- Cardiac arrhythmia
- Seizure
- Cardiac ischemia
- Sepsis
- Congestive heart failure
- Sickle cell crisis
- Croup or asthma requiring significant treatment
- Significant blood loss
- CVA, acute neurological change
- Significant complications of pregnancy
- DKA or other significant complications of diabetes
- Significant eye injury
- Endocrine emergencies
- Significant fractures or dislocations
- Epiglottitis
- Significant infection
- Exacerbation of CHF
- Significant metabolic disturbance
- Exacerbation of COPD
- Significant penetrating trauma
- Gastrointestinal obstruction
- Significant vascular disruption, aneurysm, or injury
- Hypertensive crisis
- Solid organ injury
- Intracranial hemorrhage
- Testicular torsion
- Intra-thoracic or intra-abdominal injury due to blunt trauma
- Toxic ingestion
- Kidney stone with potential complications
*It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity.
Major vs Minor Procedures/Surgeries
Minor procedure/surgery may include, but not limited to:
- Simple wound repair
- Foreign body removal
- Incision and drainage
Major procedure/surgery may include, but not limited to:
- Displaced fracture care
- Reduction of an intermediate joint dislocation, e.g., TMJ, acromioclavicular, wrist, elbow or ankle.
- Reduction of a major joint dislocation, e.g., shoulder, hip, or knee.
- Chest tube
- Cardioversion
- Endotracheal tube
Level 4 Note
CC: Ankle Sprain
Emergency Dept Physician Note History obtained from pt - reliable historian CC: Ankle Sprain HPI: 26M prev healthy with ankle twisting today, rolled ankle stepping off curb ~2hr ago. Too painful to walk despite ice so came to the ER. Pain is lateral R ankle. No weakness/numbness/tingling. No other injuries/complaints. Physical Exam: 152/85 85 20 99%RA 98F Gen: Well-appearing in NAD R Ankle Exam: Appearance/Skin: Mild swelling to lat mall; no lac, abrasion, redness noted. Bones: + mild lat mall TTP; no medial mall TTP, base of 5th MT TTP or navicular TTP. Joint: Neg squeeze test, mild decr ROM ankle 2/2 pain. Other Joints: Knee and toes FROM nontender. No fibular head TTP. Neuro: Str/sens 5/5 in all tibial and fibular nerve distributions. Vascular: 2+ DP, CR less than 2s in all toes. Compartments: Soft. Gait: Limping, requires assistance to walk. Medical Decision-Making In summary, 26M with R ankle injury with mild lat mall swelling, tenderness. Neurovasc intact. DDx: sprain vs strain; fx Plan: Motrin and ice pack, XR. Data Review & Summary XR my read — no fx noted. Emergency Dept Course & Updates Pain better after motrin and ice pack. Will dc home with ankle double-strap for support, encourage motrin at home for next 3-5 days prn. Final Disposition: Home Condition: Improved Diagnosis: R ankle sprain
Analysis
This is a standard ankle sprain visit. There's nothing special about it, and I'm truly just following the guidelines as written. I'm not upcoding or downcoding. You'll also notice that I'm not documenting a huge MDM, nor am I calling out the individual elements as they're intuitive:
- Data: I ordered an XR and interepreted it myself. Moderate complexity, Level 4.
- Risk: I did prescription drug management; I gave motrin in the ER and told him to take motrin at home. This is prescription drug management — again, I don't think it needs to be called out, because it's clear from the record that I ordered motrin. Moderate risk, Level 4.
- Problem: This is an acute, uncomplicated injury. I guess one could argue that a coder might want to know how you categorized this problem, so if needed that could be added to the MDM. Low complexity, Level 3.
Overall, this makes this a level 4 chart.