Wiki Data reviewed pathology

[ltl226]

Hello,

I was asked today if reviewing 10 pathology reports count as each data point? The question is: “when requesting medical records, is each biopsy path report it’s own data?” I am not sure reviewing 10 pathology reports count as 10 points of data reviewed.

Any help or information would be great!

Thank you,
Laura

 

[csperoni]

If you are reviewing prior external notes, you count each unique source. So if patient went to a dermatologist and had 4 biopsies, and another dermatologist and had 6 biopsies, you have 2 data points for "review of prior external note(s) from each unique source."
From the AMA 2021 Outpatient E/M Guidelines:
Unique: 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.

 

[ltl226]

Thank you so much for your response. I do not deal with the data category often and want to make sure I am giving an accurate answer.

Thank you,
Laura