Ophthalmology and Optometry Coding Alert

Hint: Look beyond the codes to the guidelines for all the info you need.

If you’re one of the many coders who find the data element of medical decision making (MDM) — formally known as the amount and/or complexity of data to be reviewed and analyzed — baffling, have no fear. We’re here to help you cut through the confusion.

Context: Now that CPT^® is using the same MDM elements for all leveled evaluation and management (E/M) services, it is more important than ever to understand how the data element works, not just on its own, but in conjunction with the elements of problems to be addressed and risk of complications.

But before we delve into the nuances of counting data, let’s briefly review the recent E/M changes.

Realize E/M Leveling Has Evolved

For the last two years, CPT^® has featured two different ways to calculate E/M levels. Since January 2021, you’ve calculated levels by meeting or exceeding the levels of two of three MDM elements: the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications of patient management. You’ve also had the option of assigning a level based on the total time the provider has spent on face-to-face and non-face-to-face activities as defined by CPT^® guidelines on the same date as the encounter.

For certain other E/M services, you have calculated E/M levels based on the documented history, exam, and MDM or typical time. But since Jan. 1, 2023, your E/M coding for consultations, inpatient admissions, subsequent care, and same-day admission and discharge services must follow the rules CPT^® established in 2021 for the office/outpatient E/M codes.

See How Data Factors Into MDM

As with the other MDM elements, the data element has four levels, though only the highest three — limited, moderate, and extensive — have requirements that must be met.

Limited: For the limited level, you must meet the requirements in at least one of the two categories:

• Category 1: Tests and documents or
• Category 2: Assessment requiring an independent historian(s)

Moderate and extensive: For the two higher data levels, the categories expand to three choices, the requirements of which have to be met for only one of the categories at the moderate level and for two of the categories at the extensive level. At these two highest levels, the independent historian is added to the tests and document category, and then there are two additional categories:

• Category 1: Tests, documents, or independent historian(s)
• Category 2: Independent interpretation of tests (not separately reported)
• Category 3: Discussion of management or test interpretation

That’s a lot of data to keep straight. But the following three tips will help if you want to use data as a part of your MDM calculations.

Hint 1: Know How to Count Tests

When the new MDM guidelines were introduced in 2021, “there were some questions or concerns about whether the combination of items from the Category 1 bulleted list had to be from different lines — Do I have to have a review of data from an external source, and a test order? — and the AMA clarified and said, ‘No. Once you have the combination of items, you can get to appropriate level in your data category,’” explained Leonta “Lee” Williams, MBA, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC, AAPC’s director of education and a healthcare management consultant for Karna, LLC, in her HEALTHCON Regional 2022 presentation “Counting of Data.”

In other words, follow the guidelines in the MDM element table, which tell you “each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.” The tests and documents section (Category 1) requires any combination of two (for the limited level) or three (for the moderate and extensive levels) of the items specified in the table to meet the data level.

Additionally, if a test is ordered outside of an encounter, or has a recurring order, the results can be counted at the subsequent encounter when analyzed/considered for treatment decisions for the patient’s care and documented to support that action.

Hint 2: Beware of Seeing Double

Another source of confusion in data counting involves how to count test ordering and test review. Simply put, if your ophthalmologist orders the test, the review would be counted with the test order unless you separately bill for the test with a CPT^® code. Per CPT^®, the test in that case “is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM,” because the physician work for that test has already been captured in a separately reported CPT^® code. “You don’t want to double dip,” cautioned Williams.

However, if an outside source orders and bills for the test, but your ophthalmologist reviews it, you can count the review as a data point for your leveling calculations.

Hint 3: Read the Definitions

“Definitions are so important in these guidelines,” Williams noted. For example, Category 3 involves “Discussion of management or test interpretation with external physician/ other qualified health care professional/appropriate source (not separately reported).”

To meet the requirements of Category 3, you must understand what CPT^® means by “external” and “appropriate source.” External in this sense means someone from “a different organization, specialty, subspecialty, or distinct group,” Williams noted. “

More importantly, the phrase “appropriate source” refers to “professionals who are not healthcare professionals but may be involved in the management of the patient,” per CPT^®. Examples include a lawyer, parole officer, case manager, and teacher but not family or informal caregivers.

Don’t Forget: Data’s Not the Only Element That Counts

If, after taking Williams’ expert hints, data counting still confuses you, remember the following advice: “Before I drive myself crazy counting data, I always start with the complexity of the condition, as well as the risks associated with treatment, and see what level I’m coming up to. Because you can use two out of the three MDM elements, I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary. I see if the level resonates with the service rendered,” advised Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC in her HEALTHCON 2022 presentation “2021 E/M Lessons Learned.”

Note: Ophthalmologists and optometrists frequently have no data elements because they rely on tests they perform in-house rather than data coming from outside sources. When the two of three rule is applied to the three MDM elements, the data score rarely contributes enough to impact the code selected.