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Data Points

The “amount and complexity of the data reviewed” are quantified by referring to the following table:
Data Reviewed Points
Review or order clinical lab tests 1
Review or order radiology test (except heart catheterization or echo) 1
Review or order medicine test (PFTs, EKG, cardiac echo or catheterization) 1
Discuss test with performing physician 1
Independent review of image, tracing, or specimen 2
Decision to obtain old records 1
Review and summation of old records 2
The physician should be aware that no “double dipping” is allowed.  For example, if you review lab results and order labs during the same visit, you only get one point (not one point for ordering and one point for reviewing).  This same rules applies to imaging  studies or other medicine tests such as EKGs or PFTs.  Commonly overlooked points are those garnered for obtaining or reviewing old records.  If you do review old records, you must summarize your findings in the chart.  It is not acceptable to just say, “Old records were reviewed.” 

E/M University Coding Tip: Notice that points can accumulate quickly if you personally review an image, tracing or specimen.  You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray).  However, you must include your own interpretation in the chart in order to claim these points. 
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