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 |
99211 |
Not applicable |
99202 99212 |
Minimal or none |
99203 99213 |
Limited Category 1: Tests and documents Any combination of 2 from the following:
-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 Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following:
-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 Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following:
-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) |