Data and Analyzed
The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter.
Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.
In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed.
For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed.
Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter.
Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.
Test
Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test.
The differentiation between single or multiple unique tests is defined in accordance with the CPT code set. For the purposes of data reviewed and analyzed, pulse oximetry is not a test
Unique Source
A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test.
Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes.
For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.
Combination of Data Elements
A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed.
It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.
External
External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization.
External physician or other qualified health care professional
An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty.
This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.
Discussion
Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange.
The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).
Independent historian(s)
An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.
In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met.
The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.
Independent interpretation
The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient.
A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
Appropriate source
For the purpose of the discussion of management data element Levels of Medical Decision Making), an appropriate source includes professionals who are not health care professionals but may be involved in the management of the patient (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.