Revenue Cycle Insider

Creating a template for practitioners can save you time and prevent errors.

In this second installment of the series, the expert-driven HEALTHCON 2026 presentation “Expert E/M Insights: Cracking the Code of the Three Key Elements of MDM,” led by Pam D’Apuzzo, CPC, CPMA, ACS EM, ACS MS, Betsy Nicoletti, MS, CPC, and Debra Rossi, CPC, CPMA, goes into detail about understanding and correctly determining the data component of the medical decision making (MDM) process.

The data element of MDM is full of complexities that can lead to undercounting or overcounting components. This practical guide breaks down the rules for reviewing, analyzing, and crediting data under the evaluation and management (E/M) guidelines.

Understand the 3 Categories of Data

“In your organizations, it’s really important that you have policy and procedure that you’re going to follow for any guidelines,” Rossi said. She provided some examples: “What will you allow? What won’t you allow? What are you going to educate providers on? Because it’s impossible to have one group of coders and you’re all following different guidelines [in the same office],” she said.   

The following are three categories Rossi gave as examples of data:

• Tests, documents, order, or independent historian(s) accounts
• Independent interpretation of a test performed by another physician or other qualified healthcare professional that is not separately reported
• Discussion of management or test interpretation with an external physician or other qualified healthcare professional or appropriate source that is not separately reported

Make note: Each data component has defined thresholds for low, moderate, and high levels of MDM.

Rossi reminded the audience that the review of results is included in the original order. “[If] you order it today, [and] you review the results at the next visit, you already got credit for review of those results when you ordered it, so you’re not counting it [again] today. That’s why it’s really important for the documentation to be clear,” she said.

She went on to explain that each unique lab is defined by the CPT^® code that is used to report the lab, lab work, X-ray, MRI, etc.

“If it’s a test you are sending to an outside vendor, you get credit for the order, but you get credit for the review at the same time. You won’t see credit at a separate visit. This is the hardest part to explain to providers,” said Rossi.

Rossi illustrated that MDM classifies data into three categories based on the type and complexity of the information being reviewed and analyzed.

Category 1 data that counts toward MDM is categorized as follows:

• Each unique test (by CPT^®) ordered or reviewed counts one time (not both)
  • “Each unique test” refers to each specific CPT^® code, not the number of test components or number of results. For example, ordering 85027 (Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)) and 80053 (Comprehensive metabolic panel) count as two unique tests.
• Review of external notes or tests results from each unique source
• Use of an independent historian when patient history is limited or unreliable; documentation explaining why an independent historian was used and who that individual was

Category 2 data (independent interpretation) is as follows:

• Personally interpret a test performed by another qualified health professional that is not separately reported (For example, echocardiogram (ECG) rhythm analysis or chest X-ray interpretation in clinic)
• Document what provider interpreted and clinical impact (for example, “CXR: no focal consolidation”)

Rossi suggested for Category 2, making sure the provider says or notes, “I personally reviewed or interpreted,” “This is my finding,” or “This is what was discussed with the patient” within the test record for these to be valid.

Category 3 data (external discussion) is as follows:

• Interactive discussion (phone, electronic, or face-to-face) related to condition management or a test interpretation
• With a physician or qualified healthcare professional not in the same specialty; document the name, credentials, date, and summary of discussion
• Asynchronous messaging (this is acceptable if it is interactive; for example, a secure chat)
  • Documentation should include name, credentials, date and time, and a summary of the discussion

See How to Count Data Correctly

Accurate MDM scoring depends on correctly counting data. Before assigning an E/M level, make sure you understand what qualifies as data and how the guidelines instruct you to count it. According to Rossi, you should choose one credit per unique test. Keep in mind that you cannot count independent interpretation if you also bill the interpretation separately. Also, multiple notes from an external source count only one time, but you can count notes from different sources separately. Be sure to document medical necessity for any data that is reviewed or interpreted.

Rossi gave the following examples according to level of complexity:

• Low complexity
  • Provider orders a rapid strep test and reviews the result with no external discussion
• Moderate complexity
  • Ordering a comprehensive metabolic panel (CMP), a chest X-ray, and then the provider reviews an outside ECG
• High complexity
  • Practitioner performs an independent ECG interpretation, the findings are listed, and discussion with the patient is clearly documented — as well as having a discussion with the cardiologist, and a review of outside records

Keep in mind: According to the Centers for Medicare & Medicaid Services (CMS) and the AMA, providers are allowed to count either ordering or reviewing the same test, not both.

Improve Documentation in Your Office

“Copy and paste is here to stay,” Rossi said. “We need to make sure that if [practitioners] are using copy and paste, they’re updating it, or they are attesting to the fact that there are no changes [to the existing text]. We don’t just want to accept everything as documented; we want to make sure we see some changes or some updates for the current date of service.”

Rossi stated that having a template that forces the providers to add specifics where asterisks are, for example, can be helpful for coders. This helps practitioners clearly document the work that was performed that day and helps coders understand how to count the data portion of the MDM.

For example, without a template, a Category 1 note from the practitioner may look like this: “Reviewed ED note from [date] and prior CXR; ordered CBC and CMP.”

With the help of a template, it could look like this:

“Test and documents: Prior report of imaging results from *** reviewed. Lab results of *** reviewed. Order [MRI/X-ray/CT scan] of ***.”

Creating templates like the one above can help remove vague mentions of records or labs simply being “reviewed” without any details, as well as naming any external parties or practitioners involved in the patient’s care.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC