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Fam Pract Manag. 2025;32(3):39

Author disclosure: no relevant financial relationships.

REVIEW OF MULTIPLE RECORDS FROM ONE SOURCE

counting data

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.

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WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.

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