Level 4 Reference Card

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99214 Major Criteria (need to meet 2 of 3)

Detailed history (need to document all 3 of the following)
- HPI: at least 4 elements for acute problems, or updates on at least 3 chronic/inactive problems
- ROS: 2 to 9 systems or body areas
- PFSH: 1 element
Detailed physical exam: 12 bulleted elements from at least 2 systems or body areas (See "General Multisystem Examination," below.)
Medical decision making of moderate complexity (need to meet 2 of 3)

A. Diagnosis and management (3 points needed)
	Problems	Points
	Self-limited or minor (such as cold, insect bite, tinea) (max. of 2)	1
	Established problem, stable/improved (no max.)	1
	Established problem, uncontrolled/worse (no max.)	2
	New problem, no further work-up (max. of 1)	3
	New problem, further work-up needed	4

B. Data (3 points needed)
	Data	Points
	Review/order lab(s) (CPT 80002-89399)	1
	Review/order radiology service(s) (CPT 70010-79999)	1
	Review/order medical diagnostic study(s) (CPT 90701-99199)	1
	Discuss test/study with performing physician	1
	Decision to obtain old records	1
	Review and summarize old records, or obtain history from someone other than patient	2
	Direct visualization and independent interpretation of an image, tracing or specimen	2

C. Risk: "Moderate risk" needed. This is subjective. Any of the following examples qualify:

Prescription drug management (e.g., new prescription, continue old)
Chronic illness: mild exacerbation, progression or side effect
2 or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis (e.g., breast lump)
Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis)
Acute complicated injury (e.g., concussion)
Stress test
Diagnostic endoscopy without risk factors
Minor surgery with identified risk factors
IV fluids with additives
Closed treatment of fracture or dislocation without manipulation

99204 Reminders

99204 has the same requirements as 99214 except: ROS, 10 or more; PFSH, 3 elements; exam, 18 bulleted elements from at least 9 systems. Also, all 3 of the major criteria must be met. These differences are summarized below.

Element	99214	99204
Major criteria (history, physical exam, medical decision making)	2 of 3	3 of 3
ROS (part of history)	2	10
PFSH (part of history)	1	3
Physical exam	12 bullets from at least 2 systems	18 bullets from at least 9 systems

General Multisystem Examination

Constitutional

vitals: 3 of 7 (BP/s-BP/pulse/resp/temp/wt/ht)
general appearance

Eyes

conjunctivae & lids
pupils and irises
scope of optic disc and posterior segments

Ears, Nose, Mouth and Throat

external ears and nose
scope of exterior auditory canals and tympanic membranes
assess hearing
nasal mucosa, septum and turbinates
lips, teeth and gums
oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, posterior pharynx

Neck

neck
thyroid

Respiratory

assess respiratory efforts
percussion of chest
palpate chest
auscultate lungs

Cardiovascular

palpate heart
auscultate heart with notations of abnormal sounds and murmurs
carotid arteries
abdominal aorta
femoral arteries
pedal pulses
extremities for edema/varicosities

Chest (Breasts)

breasts
palpate breasts and axillae

GI (Abdomen)

abdomen with notation of presence of masses or tenderness
liver and spleen
presence or absence of hernia
anus, perineum and rectum including sphincter tone, presence of hemorrhoids, rectal masses
stool sample for occult blood

Genitourinary - Male

scrotal contents
penis
digital rectal exam of prostate gland

Genitourinary - Female

external genitalia and vagina
urethra
bladder
cervix
uterus
adnexa/parametria

Lymphatic

Palpate lymph nodes in at least 2 areas:

neck
axillae
groin
other

Musculoskeletal

gait and station
inspect/palpate digits and nails

Examine joints, bones and muscles of at least one of the following: 1) head and neck; 2) spine, ribs and pelvis; 3) RUE; 4) LUE; 5) RLE; 6) LLE

inspect/palpate
assess range of motion
assess stability
assess muscle strength and tone

Skin

inspect skin and subcutaneous tissue
palpate skin and subcutaneous tissue

Neurologic

cranial nerves with notation of deficits
deep tendon reflexes (note pathological reflexes)
sensation

Psychiatric

describe patient's judgment and insight
assess orientation to time, place and person
assess recent and remote memory
assess mood and affect

Developed by James M. Giovino, MD, Mercy Health System Family Practice Residency Program, Janesville, Wis.

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