Wiki Amount and/or Complexity of Data to be reviewed and analyzed

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jonnasummers

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Help! My manager wants definition of what types of tests CAN be counted under this category. Obviously we know xrays, ekgs, etc.
For example: during an exam for shoulders injury, dr documents "The apprehension test is negative. The crossover test is negative. Hawkin's test is negative. Neer's test is negative. Sulcus sign is negative. Empty-can test is negative."

Does that count?
 
No, those are part of the physical exam. The word "test" in those statements is not data in the MDM sense.


A test is one identified by a CPT code.


Test: Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg,basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set. For the purposes of data reviewed and analyzed, pulse oximetry is not a test.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.
 
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