This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.Previously we explored the 2021 changes that effect how diagnoses will be scored. Today we will dive into the changes to the data element of MDM. We know the year 2021 will bring significant changes to how we determine the level of evaluation and management services in the outpatient setting, no longer scoring history and exam elements but instead focusing on MDM or the documentation of time. The definitions and CPT guidelines about how time and MDM are scored are also changing. In preparation of these changes, today we will focus on what we need to know and be prepared to teach our providers about how credit for complexity of data.

Currently, the 1995 and 1997 documentation guidelines label this section of MDM “Amount and/or Complexity of Data to be Reviewed,” based on “the types of diagnostic testing ordered or reviewed” and/or “a decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.” In 2021, CPT changes this heading to “The amount and/or complexity of data to be reviewed and analyzed.” Notice the new header specifies “and analyzed.” In addition to the modification to the heading, there are changes to how we credit the data elements and we are provided with definitions to assist with these changes.

Currently we give points for review and/or order of laboratory, radiology, or medicine section tests. We also credit the provider for the decision to obtain and review old medical records, obtain history from sources other than the patient, discussion of the case with other physicians and independently reviewing an image, tracing, or specimen to supplement the information found in the report of another provider. All of these actions are identified in the 1995 and 1997 documentation guidelines as work that increases the complexity of a visit. What isn’t identified in the guidelines is how to quantify this work. Enter the Marshfield tool we currently use. Using this tool, we use a point system to quantify the work and award one point for each category of testing, regardless of the number of tests reviewed, as well as points for the other elements. However, lacking any clear definition for each element of data, interpretations vary widely about when one point versus two points should be awarded for obtaining information from someone other than the patient or for performing an independent review of testing.

With the 2021 change to the heading of this element of MDM, we get more specificity on what the data to be reviewed and analyzed is. “This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not separately reported. It includes interpretation of tests that are not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.” With this statement, CPT begins to clarify how we will count data beginning next year. Further information follows. “Data is divided into three categories:

  • Tests, documents, orders, or independent historian(s). (Each unique test, order or document is counted to meet a threshold number).
  • Independent interpretation of tests.
  • Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source.”Definitions are provided in the new CPT guidelines to specify when it is appropriate to give credit for data, and how each element is counted. These include definitions of what a test is, what is considered an external record and an external physician or other qualified healthcare professional, independent historian(s) and independent interpretation, and what is considered an appropriate source as it relates to the discussion of data element. For example, the definition of independent interpretation is the “…interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

“The following is an excerpt of what we will see for this element of MDM on the new MDM:

I am certain you noticed right away that we will no longer be limited to only giving one point for the review and/or order of tests by the section of CPT as we do using the current audit tool. Instead, we are crediting complexity for the order and review of each unique test. (Thankfully they defined unique test.) Giving credit for data as we will in 2021 truly supports what the 95 and 97 documentation guidelines tell us. The more data to be reviewed and analyzed is an indication of higher complexity of the visit.

Of course, this example is only one piece of the data elements. As you read the rest of what we will be considering for this portion of MDM, there are changes in terminology that help clear up other grey areas we have struggled with for the data section. You can find the rest of the story on the changes to how the complexity of data will be addressed at

This Week’s Audit Tip Written By:
Pam is a Senior Compliance Consultant with our parent company, DoctorsManagementWhat to do next…

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