Current E/M
Amount and/or complexity of data to be reviewed and analyzed
What is data and what is "amount and complexity?": In a nutshell
Data includes review of medical records, tests, and/or information obtained from another source. It also includes ordering tests and analyzing results for the encounter.
Data is divided into three categories:
Tests, documents, orders, or information obtained from someone other than the patient (independent historian).
Independent interpretation of test.
Discussion with external physician or qualified nonphysician clinician.
Additionally, there are four levels of complexity with regard to these categories of data.
Data
There are three distinct categories of data used when determining the complexity in this element of medical decision making (MDM).
1. Tests, documents, orders, or independent historian*
Each unique test, order or document is counted to meet a threshold number
Though each unique test, order or document counts toward meeting this element, review of the results of a test you ordered are counted as part of ordering the test and not counted separately.
* Independent historian is defined as an individual who provides a history in addition to the history provided by the patient when the patient is unable to give a complete or reliable history, or a confirmatory history is necessary.
2. Independent interpretation of test(s).
This involves your independent interpretation of test(s) performed by another physician or non-physician clinician.
If the diagnostic test or study can be reported with a separate CPT code, it is NOT counted toward determining the level of this MDM element.
3. Discussion with external physician or qualified nonphysician clinician of management or test interpretation.
This excludes any discussion that are separately reported with a CPT code.
If such circumstance arises, document the reason for and the details of the discussion.
Levels of data
The amount and complexity of data element of MDM is divided into four levels:
Straightforward
Low
Moderate
High
Each level gradually increases the amount required from each data category.
See the table below as a guide for each level of complexity for this element of MDM.
| Level of MDM associated with this element (Level of service is based on 2 out of 3 Elements of MDM) | Amount and/or Complexity of Data to be Reviewed and Analyzed |
|---|---|
Straightforward |
Minimal or none |
Low |
Limited (Must meet the requirements of at least 1 out of 2 categories) Category 1: Tests and documents Any combination of 2 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test* * each test, order, or document contributes to combination of 2 or Category 2: Assessment requiring an independent historian (guardian or parent) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) |
Moderate |
Moderate (Must meet the requirements of at least 1 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 result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) * each test, order, or document contributes to combination of 3 or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported) |
High |
Extensive (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 result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) * each test, order, or document contributes to combination of 3 or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) |
Now that you have selected the level of data reviewed and analyzed, you will need at least one additional MDM element from the list below before determining the overall level of MDM for the encounter:
Ready to quantify the overall level of MDM? Use the E/M Office Visit Level of MDM Table (PDF) to determine the level of MDM and code for the encounter.
Use the Current E/M coding tool
The Academy has released a version of the E/M coding tool for the current guidance, to help dermatologists select the appropriate code.
Use the tool
You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.
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