Determining Levels of Amount and/or Complexity of Data 85 Determining Levels of Amount and/or Complexity of Data Determining Levels of Amount and/or Complexity of Data The following examples illustrate how to determine the amount and/or complexity of data to be reviewed and analyzed. Additional details show how one other element of medical ­ decision-making (MDM) is required for code selection—either the number and complexity of problems addressed or the risk of management. To better understand the following examples, see the complete elements of MDM in Table 2 of “CPT ® Evaluation and Manage­ment (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes” (available as a downloadable PDF at https://www.ama-assn.org/system/files/2019-06/ cpt-office-prolonged-svs-code-changes.pdf. EXAMPLES Example 1 An adolescent presents to her primary care pediatrician for follow-up of type 1 diabetes. The physician reviews results of laboratory tests includ- ing hemoglobin A1c (83036), urine albumin (82043), creatinine (82570), lipid panel (80061), and thyroid-­stimulating hormone (84443). (Codes are included to indicate unique tests reviewed.) The patient’s diabetes is found to be stable with no complications. Current insulin regimen is continued. The amount and/or complexity of data is moderate based on review of results of 5 unique tests (at least 3 are required for moderate amount/ complexity of data). Category 1 of the moderate level of data is met with 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, and/or assessment requiring an indepen- dent historian(s). Each unique test, order, or document contributes to the combination of 3 in category 1. In conjunction with the moderate risk of prescription drug management, code 99214 is supported. If the patient were new, code 99204 would be reported. The low number and complexity of problems addressed is not supportive of 99204 or 99214, but only 2 of 3 elements are necessary to support a level of service. Ped Office-based EM Coding booklet interior.indd 85 Ped Office-based EM Coding booklet interior.indd 85 9/14/20 12:02 PM 9/14/20 12:02 PM
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