Wiki Moderate "Category 1" Clarification for Combination of 3

[altman76]

When counting for "Category 1" (tests, documents, or independent historian) held within the moderate complexity column what is the TRUE combination of the count? There has been several interpretations to include that if a provider runs 3 tests to include individual lab tests then it is considered as 3 orderings of unique tests which qualifies as the goal met for this column in moderate. So just by ordering 3 or more tests the provider would qualify, because then so many providers across the board would qualify level 4's all day long...

EX: CMP
Lipid Panel
Obstetric Panel

Or is it that there has to be 3 out of the 4 combined below in order to qualify for the moderate complexity column?

- Review of prior external note from each unique source
- Review of the result of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian

Any input on this would be greatly appreciated as there is so many different interpretations of this being provided and we want to ensure that we are giving the most accurate info to our providers involved. Thank you in advance for any help on this.

 

[lcolborn]

Yes, 3 tests ordered or reviewed falls under the Moderate Data. There is no need to do three out of the 4 subcategories . To meet a level 4 however, you have to meet another column from the MDM Grid ( 2 out of three elements need to meet or exceed). either the Number of Complexity of Problem addressed, or the Risk of Complications column .

 

[altman76]

Yes, 3 tests ordered or reviewed falls under the Moderate Data. There is no need to do three out of the 4 subcategories . To meet a level 4 however, you have to meet another column from the MDM Grid ( 2 out of three elements need to meet or exceed). either the Number of Complexity of Problem addressed, or the Risk of Complications column .

Do you have a resource that is in print that I can present to the providers with documentation instructions? We have been looking for resources in print that reinforce these guidelines with CPT and AMA changes, but have been unsuccessful in specifics on test ordering. Thank you in advance in regards to this issue.

 

[lcolborn]

I have attended numerous Webcast and Webinars since last summer and just this week , I have attended one on how to Audit the 2021 E/M and they are all saying the same thing, including AAPC on How to audit for the 2021 E/M . I am using the MDM Grid from AMA also besides Webinars, and the CPT book for some guidance. Please see attached, so sorry if it's not a good copy.

 

[ahguzman]

Do you have a resource that is in print that I can present to the providers with documentation instructions? We have been looking for resources in print that reinforce these guidelines with CPT and AMA changes, but have been unsuccessful in specifics on test ordering. Thank you in advance in regards to this issue.

If you haven't already, I encourage you to review your payer guidelines if you're seeking guidance specifically for OB patients.

M. Guzman,
CPC, CPMA, CPC-I, CGSC, COBGC