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Evaluation and Management Coding: Medical Decision Making Moderate Point Scoring for Data Elements
On 1/1/2021, CMS approved and issued modifications to E/M coding guidelines that were originally developed and adopted by the AMA. This change included modified guidelines for MDM. National Government Services receives numerous questions on scoring the data elements segment at the moderate level. This article provides a guide to those details.
Within the data element section of MDM, a moderate level of credit may be assigned when one of the three categories below is fulfilled. Category 1 requires three points, while Categories 2 and 3 require only one point each.
Category 1 includes documents, tests or independent historian(s). Count points as follows:
- Documents: count one point for review of each external provider’s medical records (i.e., review of medical records from oncology (1) and ophthalmology (2) count as 2 points).
- Tests:
- Count review of each CPT-defined diagnostic test as one point each (except for test panels that include multiple results, e.g., CBC diff/platelets) (i.e., review of MRI, CT scan and chest X-ray (3) counts as three points).
- Count an order for each CPT-defined diagnostic test as one point each (except for test panels as described above) (i.e., orders for a CBC diff, thyroid panel, chest X-ray count as three points).
- Independent Historian(s): Allow one point when the patient’s history is obtained from an independent historian (e.g., parent, guardian, caregiver).
- Note: When three points are achieved within Category 1, the category has been satisfied and the provider may allow moderate credit in the data element section of MDM.
Category 2 includes independent interpretation of tests. Count points as follows:
- This category is fulfilled when reviewing results and/or interpretations of singular or multiple tests previously performed by another provider. Count one point for this fulfilled category.
- The one point allotted in this category satisfies the requirement and the provider may allow credit as moderate in the data element section of MDM.
Category 3 includes discussion of management or test interpretation. Count points as follows:
- This category is fulfilled when the provider discusses the management of the patient’s care and/or reviews diagnostic test results with another qualified provider.
- Credit may not be allowed in Category 3 if this professional consultation has already been billed as a separate service (e.g., internet consultation request, CPT 99452).
Reviewed 3/17/2023