Overcoming Your “Level 5” Fears, Part II

June 26, 2023

To almost quote a famous president, the only thing to fear about Level 5 is fear itself — PROVIDED that you document, document, document. In the previous edition of Coffee & Coding, we debunked some of the scary myths that keep providers from applying Level 5 codes (99205/99215) when appropriate. Now let’s look at how to meet the Complexity of Data and Risk requirements to properly code E/M services as Level 5.

Complexity of Data

The requirements are the same as for the 99213 and 99214 codes, except for the amount of information needed. You must meet two out of the three categories. Additionally, you must fulfill at least three of the requirements from Category 1, in addition to the requirements from either Category 2 or Category 3. See below:

(must meet the requirements of at least 2 out of 3 categories)
Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following:

  • Review of prior external note(s) from each unique source
  • Review of the results of each unique test
  • Ordering of each unique test
  • Assessment requiring an independent historian(s)
Category 2: Independent interpretation of tests Independent interpretation of a test performed by another physician/other qualified healthcare professionals (not separately reported)
Category 3: Discussion of Management or test interpretation Discussion of management or test interpretation with external physician/other qualified healthcare professional/appropriate source (not separately reported)


Level 5 requirements for RISK involve the greatest difficulty. Let’s break them down and simplify some examples. Here are instances of high risk associated with morbidity from additional diagnostic testing or treatment:

  • Drug therapy requiring intensive monitoring for toxicity
    • Any drug that necessitates constant monitoring for toxicity, such as chemotherapy or bipolar medications, meets this requirement.
  • Decision regarding elective major surgery with identified patient or procedure risk factors
    • Any surgery that can be postponed for more than 24 hours falls into this category. Examples include cosmetic surgery, joint replacement, endoscopy, carpal tunnel syndrome (CTS) surgery, kidney stone removal, and tonsillectomies.
  • Decision regarding emergency major surgery
    • Examples would include treatment of broken bones, appendicitis, and gall bladder removal.
  • Decision regarding hospitalization
  • Decision not to resuscitate or to de-escalate care because of poor prognosis
    • Discussions about do-not-resuscitate (DNR) or do-not-intubate (DNI) qualify. Calling for an ambulance and arranging a warm handoff also meets this requirement.

Beyond the examples listed here, other factors within the same category can contribute to meeting the high risk of morbidity requirement. For instance, stabilizing a patient in the office with constant monitoring (where time plays a role) and documenting the actions taken would be considered. If you simply had the patient lie down and observed them, that wouldn’t fulfill the requirement. However, if you initiated hydration, performed compressions, stabilized wounds, and spent more time with the patient, it would be considered towards meeting the requirement.

I have witnessed some “once in a lifetime” events that would qualify as Level 5. For example:

  • A doctor jumped in the back of an ambulance with a pediatric patient.
  • A patient with a DNR/DNI directive died in the office.
  • A patient required compressions in the waiting room before even getting seen.

Obviously, the published guidelines cannot encompass every possible scenario that may qualify for Level 5. However, if you invest time in caring for a challenging patient, do not hesitate to document the time spent and the actions taken. For instance, an Alzheimer’s patient requiring 70 minutes of provider time for care coordination can meet the requirement.

The Bottom Line

Don’t be afraid to code Level 5. Remember, it’s all about your actions, addressing co-morbidities, and thorough documentation. And, again, if you didn’t document it, it did not happen.

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Michelle Sergei-Casiano - Complexity of Data
Michelle Sergei-Casiano - Complexity of Data
Michelle Sergei-Casiano

Senior Manager, Regulatory and Coding Compliance

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