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MDM - Data

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KoBee

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Under the 2021 E/M guidelines for Category 1 (Data) at the moderate level, each bullet represents a distinct type of clinical action. The wording “ordering of each unique test” is plural, but counts as only one category element, regardless of how many tests are ordered.

In this case, the provider ordered:

  • POCT glucose
  • POCT hemoglobin
  • POCT urinalysis
Since all of these fall under “ordering of tests,” does this count as only one data element, meaning the visit supports low data rather than moderate data?
 
Hi, you count each unique test ordered. In your CPT manual the top of data analyzed column in the MDM chart states:
*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.
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In your example that's three tests. CPT Assistant 5/2021 has a Q&A that addresses this.
 
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