Has there been any clarification from the AMA or CMS on how to count the Data Level Points?
There is confusion in how to count the Data Level. Below is how the AAPC has documented how to count points.
The 2021 MDM table in the CPT® E/M guidelines has three main columns with the final column divided into three additional columns:
Ordering a Test is Credited Separately from Reviewing that Test
A big change in the 2021 E/M guidelines is that you can give the provider credit for both ordering and reviewing the same test. The 1995/1997 E/M guidelines credited both pieces together. The credit hinges on the review date. Assign the point based on these scenarios:
Same session results: Provider orders and performs the lab in-house and has the results before the patient leaves. Do not give credit for the order or review.
Different day results provided with no subsequent encounter. A patient’s labs come back a couple days after the visit, and the physician calls the patient to discuss the results. The provider prescribes a medication and amends the documentation for the E/M visit to include review of the test results. You should give the provider credit for both ordering and reviewing the test on that same visit.
Different encounter for results review: A provider orders the test, receives the results after the visit, and then schedules a follow-up visit with the patient in which the test results are reviewed and discussed. Should you count the review of the test results at the first encounter when you’re documenting the discussion of the results at the subsequent encounter? Not all experts agree.
CPT language: “Ordering a test is including in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter,” according to the 2021 E/M guidelines. Based on this language, some experts advise you’d credit both ordering and reviewing at the initial visit. In other words, it’s assumed that if a provider orders a test, he or she intends to review it eventually.
Confusion: Other experts say the review should be credited on the subsequent visit, because the notes for that visit will indicate the review and discussion.
Do this: This is a gray area, and perhaps AMA, CMS, and payers will offer clarifications in 2021. In the meantime, your practice should decide on one interpretation or the other, document that interpretation in your policies and procedures, and have all providers abide by that policy. If CPT or CMS does eventually provide a clear interpretation, amend your policy
It seems to me, if a physician orders a test, they cannot make a decision until they know what is going on with the patient. Therefore, the physician would need to both order and review before making a decision. Why would a physician only get one point, when there are two steps to follow? If the test ordered required scheduling, etc. then obviously, the physician would get one point for ordering, as they would review with the patient at later date. However, most physicians will call the patient and review with them over the phone, so should the note be held until there is a phone call with the patient? We are struggling with this area and need more clarification. Are there any definitive answers out there yet? If so, could you direct them to me. Thank you.
Lorraine Wannebo, CPC
There is confusion in how to count the Data Level. Below is how the AAPC has documented how to count points.
The 2021 MDM table in the CPT® E/M guidelines has three main columns with the final column divided into three additional columns:
- Code
- Level of MDM (Based on 2 out of 3 Elements of MDM)
- Elements of Medical Decision Making
- Number and Complexity of Problems Addressed at the Encounter
- Amount and/or Complexity of Data to be Reviewed and Analyzed
- Risk of Complications and/or Morbidity or Mortality of Patient Management
Ordering a Test is Credited Separately from Reviewing that Test
A big change in the 2021 E/M guidelines is that you can give the provider credit for both ordering and reviewing the same test. The 1995/1997 E/M guidelines credited both pieces together. The credit hinges on the review date. Assign the point based on these scenarios:
Same session results: Provider orders and performs the lab in-house and has the results before the patient leaves. Do not give credit for the order or review.
Different day results provided with no subsequent encounter. A patient’s labs come back a couple days after the visit, and the physician calls the patient to discuss the results. The provider prescribes a medication and amends the documentation for the E/M visit to include review of the test results. You should give the provider credit for both ordering and reviewing the test on that same visit.
Different encounter for results review: A provider orders the test, receives the results after the visit, and then schedules a follow-up visit with the patient in which the test results are reviewed and discussed. Should you count the review of the test results at the first encounter when you’re documenting the discussion of the results at the subsequent encounter? Not all experts agree.
CPT language: “Ordering a test is including in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter,” according to the 2021 E/M guidelines. Based on this language, some experts advise you’d credit both ordering and reviewing at the initial visit. In other words, it’s assumed that if a provider orders a test, he or she intends to review it eventually.
Confusion: Other experts say the review should be credited on the subsequent visit, because the notes for that visit will indicate the review and discussion.
Do this: This is a gray area, and perhaps AMA, CMS, and payers will offer clarifications in 2021. In the meantime, your practice should decide on one interpretation or the other, document that interpretation in your policies and procedures, and have all providers abide by that policy. If CPT or CMS does eventually provide a clear interpretation, amend your policy
It seems to me, if a physician orders a test, they cannot make a decision until they know what is going on with the patient. Therefore, the physician would need to both order and review before making a decision. Why would a physician only get one point, when there are two steps to follow? If the test ordered required scheduling, etc. then obviously, the physician would get one point for ordering, as they would review with the patient at later date. However, most physicians will call the patient and review with them over the phone, so should the note be held until there is a phone call with the patient? We are struggling with this area and need more clarification. Are there any definitive answers out there yet? If so, could you direct them to me. Thank you.
Lorraine Wannebo, CPC
