REVIEW OF MULTIPLE RECORDS FROM ONE SOURCE
What amount and/or complexity of data is supported when I review multiple hospital records, including records from radiology, laboratory, the patient's hospitalists, and one or more subspecialists?
All of the hospital's records together count as a single external record when determining the amount and/or complexity of data reviewed and analyzed. The hospital is one unique external source of data, regardless of how many departments created the records. Therefore, the records count as one item of Category 1 data reviewed and analyzed, which alone would support a minimal amount and/or complexity of data. For time-based coding, you may include your review of the records in your total time if you reviewed them on the same date as the visit.
The same rules apply in similar situations where you receive and review multiple records from a single physician. For example, let's say you review three encounter notes from another physician in your practice. Even though you're in the same group practice, they count as an external source as long as their specialty or subspecialty is different from your own. But just as with the above hospital records, reviewing multiple documents from that same physician would only count as one piece of Category 1 data.
Another example would be reviewing a laboratory test that provides results for multiple viral pathogens. When a single lab test provides multiple results (e.g., influenza A, influenza B, and COVID-19), it is reported with one CPT code and is therefore considered one test ordered or reviewed per CPT E/M coding guidelines. It's one piece of Category 1 data, just as with the above two examples.
REVIEW OF EXTERNAL NOTES AND INCLUDED TEST RESULTS
When I review external notes from a physician in another specialty related to a patient visit, does the review of any test results included with the specialist's notes count separately toward the amount and/or complexity of data I review and analyze?
No, count all data received from one external source (e.g., specialist, hospital, or lab) once toward the amount and/or complexity of data reviewed and analyzed. However, if you receive notes from two distinct specialists, you may count them as two external sources. For example, if you review consultation reports from an endocrinologist and a cardiologist and use them in medical decision making for the same patient visit, that counts as two pieces of Category 1 data.
REVIEW OF DATA FOR TESTS ORDERED OUTSIDE A VISIT
When do I count the amount and/or complexity of data when I order one test at an office visit but the next day the patient's health plan refuses to authorize the test and requires a new order for a different test? Can I count the review of the test ordered outside the visit when the patient presents for the next visit?
This scenario calls for a certain amount of clinical judgment. Deciding to order an alternative test requires new medical decision-making, and you didn't count the order for the alternative test at the time of the prior E/M service. The American Medical Association has indicated that for tests ordered outside a visit the review of results is counted at the next encounter. However, you should consider the significance of the change and the impact on the risk of patient management before choosing to count the review of the alternate test at the next visit. It may be helpful to add a note to your documentation explaining why you ordered the new test (e.g., “Insurance denied coverage for XYZ test. Therefore, I reevaluated the patient condition and decided to use ABC test”).
