Pediatric Coding Alert

Identify situations when it’s best to not count data

If you’re like many coders and are continuously confused when counting data toward medical decision making (MDM), then settle in. We’re here to help you find your way in and out of the data element, more formally known as the amount and/or complexity of data to be reviewed and analyzed, just in time for the evaluation and management (E/M) updates that lurk right around the corner.

Know How Data Factors Into MDM

As you probably know, starting Jan. 1, 2023, E/M coding for inpatient admission, subsequent care, and same-day admission and discharge will start following rules like the ones CPT^® established in 2021 for the office and other outpatient E/M codes. (You can read more about that in Pediatric Coding Alert, Volume 25, Number 9.) That makes now a smart time to get all your questions about counting data toward MDM answered.

Consistent with the other MDM elements, the data element has four levels, though only the highest three — limited, moderate, and extensive — have specific 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 for 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
• 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 [the] 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 that “each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1.”

Hint 2: Beware of Seeing Double

Another source of confusion in data counting involves how to count test ordering and test reviewing. Simply put, if your pediatrician orders the test, the review would be counted with the test order. The exception is any service for which the professional component is separately reported by the physician or Qualified Healthcare Professional (QHP) reporting the E/M service. 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/QHP 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 PCP reviews it, you can count the review as a data point for your levelling calculations.

Hint 3: Read the Definitions

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

So, 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 cautioned.

More important, 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. The definition does not include discussions with family or informal caregivers.

Remember: Data’s not the Only Element That Counts

If, after taking Williams’ ints, 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 presentation “2021 E/M Lessons Learned,” at HEALTHCON 2022.