I'm being told tests of the same "type" such as Radiology, can only be counted ONCE for Category 1 (Tests, Documents, Orders, Independent Historians). I've read all CPT guidelines regarding the amount/complexity of data many times over, and do NOT think this is correct. The only time I've counted several tests as ONE data element is when the tests are from one external source (each external source is counted once), OR labs with overlapping elements, such as CMP and Electrolyte panel = 1 test since electrolyte panel is included in CMP.
I'm coding for the ED physician in this case. Patient fell and has pain in her left upper extremity. X-rays of the left elbow, left forearm, and left wrist were taken. Here is the relevant documentation (in purple):
LABS, X-RAYS, AND EKG
Lt Elbow X-ray: (FINDINGS: Multiple views of the elbow show a fracture-dislocation. The ulna and radius are displaced posteriorly relative to the humerus. A fracture fragment is seen which may be part of the radial head and may also be part of the olecranon. There are fracture fragments just superior to the humeral condyles and in the joint space of the ulna and inferior to the humeral condyles.
IMPRESSION: Elbow fracture-dislocation.
Electronically signed by [Radiologist]
The X-rays were interpreted by the radiologist. Prior films were not available for comparison.
Lt Forearm X-ray: (FINDINGS: 2 views of the forearm again show an elbow fracture-dislocation. This is better described on the elbow films. The shafts of the ulna and radius appear intact.
IMPRESSION: Elbow fracture-dislocation.
Electronically signed by [Radiologist]
The X-rays were independently viewed by me and interpreted contemporaneously by me. The X-rays were interpreted by the radiologist. Prior films were not available for comparison.
Lt Wrist X-ray: (FINDINGS: Multiple views of the left wrist show normal bone density and alignment. No fractures demonstrated. Articular spaces are maintained.
IMPRESSION: No acute bony injury.
Electronically signed [Radiologist]
Course of Care: Patient is a female presents with left elbow/forearm pain after a mechanical fall. Slight abrasion to forehead, no LOC, headache, mental status changes.
Patient did not have chest pain, dizziness, difficulty breathing at any point.
Tenderness to forearm, particularly at elbow. NVI distally.
X-rays show fx dislocation at elbow.
Conscious sedation provided, elbow successfully reduced and splinted. NVI after procedure.
Patient will follow-up with ortho, will return if worse in any way.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis and need for follow-up.
Medication administered under direct supervision of physician; IV fluid administered under direct supervision of physician for 1 hour or less.
Disposition: Condition: good and stable. Discharged.
CLINICAL IMPRESSION
Left radial head fracture and left olecranon fracture.
Dislocated left elbow with reduction in ER, associated with radius fracture.
Fall.
INSTRUCTIONS
Wear simple sling until released. Wear splint for one week. Return for worsening pain or if worse in any way. (Otherwise, follow-up with orthopedics as discussed.).
[ED Physician]
Electronically signed by [ED Physician]
My calculation for amount/complexity of Data:
3 unique tests ordered (X-ray of elbow, X-ray forearm, X-ray wrist) (satisfies Category 1), +
1 Independent Interpretation (not separately reported) (satisfies Category 2)
= Extensive
I'm being told this is wrong, and was sent an email (red text) stating:
For E/M Medical Decision Making (MDM), CPT guidelines do not count data based on the number of CPT codes, but rather by category of data.
For Amount and/or Complexity of Data, tests are grouped into categories. Specifically:
Independent interpretation of X-ray → adds ONE additional element
I'm coding for the ED physician in this case. Patient fell and has pain in her left upper extremity. X-rays of the left elbow, left forearm, and left wrist were taken. Here is the relevant documentation (in purple):
LABS, X-RAYS, AND EKG
Lt Elbow X-ray: (FINDINGS: Multiple views of the elbow show a fracture-dislocation. The ulna and radius are displaced posteriorly relative to the humerus. A fracture fragment is seen which may be part of the radial head and may also be part of the olecranon. There are fracture fragments just superior to the humeral condyles and in the joint space of the ulna and inferior to the humeral condyles.
IMPRESSION: Elbow fracture-dislocation.
Electronically signed by [Radiologist]
The X-rays were interpreted by the radiologist. Prior films were not available for comparison.
Lt Forearm X-ray: (FINDINGS: 2 views of the forearm again show an elbow fracture-dislocation. This is better described on the elbow films. The shafts of the ulna and radius appear intact.
IMPRESSION: Elbow fracture-dislocation.
Electronically signed by [Radiologist]
The X-rays were independently viewed by me and interpreted contemporaneously by me. The X-rays were interpreted by the radiologist. Prior films were not available for comparison.
Lt Wrist X-ray: (FINDINGS: Multiple views of the left wrist show normal bone density and alignment. No fractures demonstrated. Articular spaces are maintained.
IMPRESSION: No acute bony injury.
Electronically signed [Radiologist]
Course of Care: Patient is a female presents with left elbow/forearm pain after a mechanical fall. Slight abrasion to forehead, no LOC, headache, mental status changes.
Patient did not have chest pain, dizziness, difficulty breathing at any point.
Tenderness to forearm, particularly at elbow. NVI distally.
X-rays show fx dislocation at elbow.
Conscious sedation provided, elbow successfully reduced and splinted. NVI after procedure.
Patient will follow-up with ortho, will return if worse in any way.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis and need for follow-up.
Medication administered under direct supervision of physician; IV fluid administered under direct supervision of physician for 1 hour or less.
Disposition: Condition: good and stable. Discharged.
CLINICAL IMPRESSION
Left radial head fracture and left olecranon fracture.
Dislocated left elbow with reduction in ER, associated with radius fracture.
Fall.
INSTRUCTIONS
Wear simple sling until released. Wear splint for one week. Return for worsening pain or if worse in any way. (Otherwise, follow-up with orthopedics as discussed.).
[ED Physician]
Electronically signed by [ED Physician]
My calculation for amount/complexity of Data:
3 unique tests ordered (X-ray of elbow, X-ray forearm, X-ray wrist) (satisfies Category 1), +
1 Independent Interpretation (not separately reported) (satisfies Category 2)
= Extensive
I'm being told this is wrong, and was sent an email (red text) stating:
For E/M Medical Decision Making (MDM), CPT guidelines do not count data based on the number of CPT codes, but rather by category of data.
For Amount and/or Complexity of Data, tests are grouped into categories. Specifically:
- Category 1 includes “Tests, documents, orders, or independent historian(s)”
- Within Category 1:
- Multiple tests within the same CPT-defined group (e.g., radiology) are counted as ONE element, regardless of how many individual studies are performed.
Independent interpretation of X-ray → adds ONE additional element
Total Data Calculation
- Radiology tests (same category) → 1
- Independent interpretation → +1
