American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Element 2: Data Reviewed and Analyzed

2. The amount and/or complexity of data to be reviewed and analyzed.

This element recognizes each unique test, order, or document to meet the requirements for each level of MDM. Tests can include imaging, laboratory, psychometric, or physiologic data. The difference between single or multiple unique tests is based on the applicable CPT code(s) for such tests. For example, CPT code 80047 describes a clinical laboratory panel that includes and requires multiple tests but is considered a single test because only one CPT code is reported.

Important for surgeons: Independent interpretation of a test performed by another physician and not separately reported by the surgeon (e.g., independent interpretation of a chest x-ray) meets a criterion for this element as "data analyzed." In addition, discussion of patient management (e.g., surgeon and physical therapist) or test interpretation with external physicians (e.g., surgeon and pathologist) meets a criterion for this element. However, external physicians cannot be in the same group practice or same specialty/subspecialty as the billing surgeon. For example, reviewing an image with your office partner would not count as a criterion for this element.

Office/Outpatient E/M Visit CPT Code

2) Amount and/or Complexity of Data to be Reviewed and Analyzed

*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.

99211 Not applicable
99202
99212

Minimal or none

99203
99213

Limited
(Must meet the requirements of at least 1 out of 2 categories)

Category 1: Tests and documents
Any combination of 2 from the following:

  • Review of prior external note(s) from each unique source*
  • Review of the result(s) of each unique test*
  • Ordering of each unique test*

-or-

Category 2: Assessment requiring an independent historian(s)

(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)

99204
99214

Moderate
(Must meet the requirements of at least 1 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:

  • Review of prior external note(s) from each unique source*
  • Review of the result(s) of each unique test*
  • Ordering of each unique test*
  • Assessment requiring an independent historian(s)

-or-

Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

-or-

Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

99205
99215

Extensive
(Must meet the requirements of at least 2 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:

  • Review of prior external note(s) from each unique source*
  • Review of the result(s) of each unique test*
  • Ordering of each unique test*
  • Assessment requiring an independent historian(s)

-or-

Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

-or-

Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

View the Office E/M Coding Changes Guide