Should I use Data to be Reviewed and Analyzed: Minimal or None?

This week’s question: “Could you please explain what the Minimal Data to be Reviewed check box would be used for? In what instances would we use this?”

The AMA’s Data to be Reviewed and Analyzed column lists “Minimal or none”  as part of the definition for a Straightforward MDM.

A Straightfoward MDM defines the lowest E/M code level a provider will be coded – an E/M code “level 2” – 99202 or 99212.

Whatever “cheat sheet,” software, checklist you are using, coding an E/M code using “no data reviewed or analyzed” seems counter intuitive and may be difficult to defend.

If we look at the pre-2021 (1995 / 1997) MDM’s Data to be Reviewed and Analyzed – it also lists tests, old records, external sources, etc.

AMA – E/M Office Visit 2021

Slides 50 says

MDM: Amount and/or Complexity of Data to be Reviewed and Analyzed

• Simplified and standardized contractor scoring guidelines

• Emphasized clinically important activities over number of documents

• Need to account for quantity of documents ordered/reviewed (as it is MDM work)

Note that the goal for the Data to be Reviewed and Analyzed section is meant to quantify its impact on the effort in medical decision making (“it is MDM work”).

As we’ve highlighted in prior articles, having a definition for 99202 or 99212 and/or asking providers to document for complexity of diagnosis and risk of morbidity would provide a more compliant process to bill for any E/M code.

With a “grey area” such as Data To be Reviewed minimal or none, how providers are trained to document will need to be defensible in a retrospective audit review. It is best to document the methods and definitions your organization defines in your standard operating procedures.

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