Requirements for Billing an Established Level 4 Visit

Medical Decision-Making Requirements

The American Academy of Sleep Medicine recommends that moderate complexity medical decision-making for a level 4 established patient visit includes at least two of the following elements: moderate number of diagnoses or management options, moderate amount of data to review, and moderate risk of complications, morbidity, or mortality 2
Moderate complexity medical decision-making is required for a level 4 established patient visit, which includes elements such as moderate number of diagnoses or management options and moderate risk of complications, morbidity, or mortality 3

A total face-to-face time of at least 25 minutes with more than half spent counseling the patient is required for a level 4 established patient visit, as recommended by the American Academy of Pediatrics 1
For telehealth visits, the total time must be documented in the visit note, according to the American Gastroenterological Association 4

A detailed interval history is required to support a level 4 established patient visit, as recommended by the American Academy of Pediatrics 1
Moderate complexity medical decision-making must be documented to support a level 4 established patient visit, according to the American Academy of Sleep Medicine 3
For telehealth visits, additional documentation requirements include patient consent to telemedicine, method of telemedicine, patient location, provider location, clinical participants' roles and actions, and other individuals present at the visit, as recommended by the American Gastroenterological Association 4

The American Medical Association recommends using appropriate CPT codes, such as 99214 for established level 4 patients 3
For telehealth visits, the American Gastroenterological Association recommends including the appropriate Place of Service code and telehealth CPT modifier based on payer specifications 4
Proper documentation of time spent is required if billing based on time rather than complexity, according to the American Gastroenterological Association 4