Data

Data works very similarly to problems and is based on a point system:

 

Minimal complexity = 1 point from below (99202 or 99212)

Low complexity = 2 points from below (99203 or 99213)

Moderate complexity 4 = 3 points from below (99204 or 99204)

High complexity 5 = 4 points from below (99205 or 99215)

 

Review or order lab tests (rapid strep and CBC), 1 point

Review or order other radiology test (chest x-ray, etc.), 1 point

Review or order echo, PFTs, or EKG, 2 points

Discuss test with performing physician, 1 point

Independent review of image or tracing (EKG or chest x-ray), 2 points.

Review and summary of old records, 2 points.

 

Note that you can only get one lab point no matter how many lab tests you order on one day.  Ordering a UA, CBC, BMP, LFTs, hCG, sweat chloride test, and wound culture on one person only counts as one point.  If you review those labs that day you still only get one point.  However, if you order the labs on one day and review them on a follow-up visit in two weeks, you could get 1 point on the day you order them and 1 point on the day you review them.  If you diagnose a patient with hypertension, you may order a BMP, chest x-ray, and EKG while they are in the office and personally review the EKG.  This would give you 5 data points for that day.  If you see them back in 2 weeks and review their chest x-ray report and bloodwork, you could get 2 data points that day.

 

In virtually all cases, however, if you are obtaining a level 4 or 5 amount of data, you are already meeting the criteria for a level 4 decision making based solely on diagnoses and risk.  Remember, to qualify for level 4 decision making for any patient, you must only meet two of the three criteria (diagnoses, data, or risk).