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POINTS FOR REVIEW
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Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
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You can get two data points if you personally review an image, tracing or specimen. It does not matter if there is an official report already in the record (for example an official interpretation from a radiologist for a chest X-ray). All that is required is that you personally eye-ball the image, tracing or specimen AND record YOUR findings in the chart.
It is not known (and in fact be unknowable) whether or not there is a limit on the amount of points you can accumulate for personally reviewing an image, tracining or specimen. For example, if you are admitting a patient with chest pain it would not be unusual for you to look at a chest X-ray and an EKG. As long as you record your findings in the chart, it seems reasonable that you would be able to claim four data points for this cognitive labor. To be on the safe side, however, we recommend that you pose this specific question to your Medicare carrier.
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