Level 4 Chart Documentation Requirements
I cannot provide a definitive answer to this question because the evidence provided does not address medical chart documentation levels or the specific requirements for "level 4" charting in the context of evaluation and management (E/M) coding.
Why This Question Cannot Be Answered From the Evidence
The studies and guidelines provided focus on:
- Cancer family history collection for oncology patients, emphasizing first- and second-degree relatives 1
- Psychiatric family assessment in child and adolescent psychiatry, covering family dynamics and interaction patterns 1, 2
- General medical history taking across various specialties 1, 3, 4
- Family history as a public health tool for disease prevention 5, 6, 7
None of these sources define or reference "level 4 chart" requirements, which typically refers to E/M coding levels established by CMS (Centers for Medicare & Medicaid Services) or similar billing/documentation frameworks.
What the Evidence Does Address
Comprehensive Family History Standards
For cancer patients, the American Society of Clinical Oncology recommends documenting:
- First-degree relatives (parents, children, full siblings) 1
- Second-degree relatives (grandparents, aunts/uncles, nieces/nephews, grandchildren, half siblings) 1
- Type of primary cancer(s), age at diagnosis, and lineage (maternal/paternal) for each affected relative 1
For psychiatric evaluations, the American Psychiatric Association recommends documenting:
- History of suicidal behaviors in biological relatives (for patients with suicidal ideation) 1
- History of violent behaviors in biological relatives (for patients with aggressive ideation) 1
Clinical Context Note
If your question pertains to E/M coding levels (CPT codes 99201-99215 or their current equivalents), you would need to consult:
- Current CMS documentation guidelines
- The 2021 E/M guidelines (which shifted from history-based to time-based or medical decision-making criteria)
- Your specific payer's requirements
The answer would depend on whether you're using the 1995 guidelines, 1997 guidelines, or post-2021 guidelines, as the requirements differ substantially.