# MDM- "Amount and/or Complexity of Data Reviewed"



## CoderinJax (May 15, 2018)

I am in need of some advice on some records I'm reviewing. This is directly related to the *"Amount and/or Complexity of Data Reviewed"* of the MDM component.

If the Physician notes she performs a "Urine Toxicology Screening", checking for RX compliance, and mentions she *personally "reviewed the dipstick herself which provides a preliminary result for the potential of more or more drugs",* how many points does this qualify for? 

One total, for the review and/or order of clinical labs?
Two total, for the independent visualization of a specimen?
Three total, for ordering/reviewing and also independent visualization?

I've seen many conversations about this, but no hard documentation that says truly which one. I've researched in Optum's Evaluation and Management Coding Advisor and it isn't answered for my scenario. I've Googled and can only find opinions, but nothing from bigger reputable sources. If anyone has something in writing I would greatly appreciate it!

Thanks so much!


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## ellzeycoding (May 15, 2018)

1 point.

You do not get credit for ordering and separate credit for reviewing on the same visit.  Ordering *or *reviewing.

https://emuniversity.com/ClinicalLabTests.html


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## CoderinJax (May 15, 2018)

*Thank you!*

Thanks for that, Karl! 
Do you know by chance where E/M University could be pulling that from? I don't know that I can use them as a source to support what I'm seeing. 
That scenario appears to be only in regards to the And/Or statement of the MDM since it's mentioning the "ONE point", and what I'm seeing is the ordering/reviewing (which would only be 1 point), but ALSO the direct visualization of the dipstick, which is where the TWO points comes in. (Make sense?)


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## ellzeycoding (May 15, 2018)

Not sure of the source.

I don't think the independent visualization applies to the clinical lab tests.  I think you would still get one point for ordering/reviewing

Here is what E/M Universtiy states on "independent visualization". They sort of defer to the Medicare contractor.

https://emuniversity.com/PointsforReviewofImageorTracing.html

Others may chime in differently though and I may be wrong.

CMS E/M guidelines state

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

The direct visualization and independent interpretation of an image, tracing or specimen *previously or subsequently interpreted by another physician should be documented. *

So if this was just an in-office lab test and it wasn't previously interpreted by another physician, I don't think you get credit for "independent visualization"


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## CoderinJax (May 23, 2018)

*Credit for visualization*

"The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented. 
So if this was just an in-office lab test and it wasn't previously interpreted by another physician, I don't think you get credit for "independent visualization"

-Okay, great! This is what I'm going to go with as well after further research. It appears the intent was when a Physician has to look at something someone else did, as you mentioned above. Thanks again!


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## adamchadwick (Jun 5, 2018)

*MDM complexity reviwed*

i have one real confusion regarding complexity data portion...IN inpatient setting, during hospital stay, if a provider reveiw the radiology report we give it one point, and if he also document the reports of previous 1 or two dates( that are already reveiwd in previous dates during that stay) can we give two points for it as old records reveiwed?? if not any CMS documentation?? really need help regarding this...thanks in advance


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