MDM Data – What Counts?

Many of you have seen, read and/or heard PRS teach Evaluation and Management coding. Over the years, PRS has provided education for documentation and auditing of E/M services in seminars, web courses, Webinars and articles. Some of you have contracted with us for instructive audits, others have relied on us to defend their practice from payer audits and takebacks and a few practices have worked with PRS to help get back into the good graces of Medicare using PRS as an Independent Review Organization. PRS methods for E/M coding have been tested in court and reviewed by State and Federal branches of the government and lauded by Medicare Medical Directors.

Over the years, we have adapted our teaching, auditing and reminder tools to conform to official changes in rules and to the more subtle changes that have been developed by auditors. More recently, we have seen a shift from auditors and in rules for 2019 to a focus on Medical Decision Making as the primary driver of appropriate code level. Although the guidelines remain in place until CPT changes go into effect in 2021, we have changed our primary audit criteria requiring MDM to meet or exceed the level of service selected in the vast majority of cases. PRS has elected not to change its primary E/M reminder tools (the Pocket Card and Wall Chart) until CPT changes are published.

The AMA has announced they will make changes in the 2021 CPT manual that will require changes in the CMS documentation guidelines and auditing criteria. The Center for Medicare and Medicaid Services (CMS) is the impetus for this change that will codify a shift away from Hx and PE check lists. When implemented code level selection will be based on MDM or Time documentation. Throughout the next year PRS will continue to provide updates and suggestions to prepare for the 2021 changes as well as introduce the updated version of the Pocket Card and Wall Chart.

The projected changes are going to require a few changes in how MDM is scored, however, conceptually MDM will be very similar to what is currently in place.

In preparation for the changes next year, we are going to release a series of articles on current Medical Decision Making requirements. As these rules remain in place and in focus for audits under existing rules, and we are moving to a more MDM centric set of rules for the future we are focusing E/M training and audits for 2020 on MDM foundation training. With a strong foundation in current rules the change in 2021 will be made easier.

Remember that there are three sub-components of MDM (Number of Diagnoses/Problems, Amount of Data and Amount of Risk) and two out of three must meet or exceed the level of service reported. In this article we will focus on the Data component of MDM in the current rule set. We will focus on the other two sub-components of Number of Problems/Diagnoses and Amount of Risk in later articles.


Data as a sub-component of MDM has been confusing for many. There are a number of reasons that Data has been a stumbling block, not the least of which stem from the lack of clarity in the official documentation guidelines. The lack of clarity has led to a number of different systems, including ours, to count DATA within the E/M coding structure. Another point of confusion is what to classify as data in relation to subjective information classified as History.

Counting Data

There are at least three published methods for scoring data during an E/M audit. The PRS data method, the Marshfield Clinic Data and a scoring system suggested but not officially adopted by trailblazers are the three most commonly referenced methods we have seen. Admittedly we have significant bias as the developer of the PRS system. We can comfortably state that all three systems have wide-spread adoption, and each has been thoroughly tested by payers, courts and provider groups across the country. As we have taught over the years, clear reference to the system agreed to by your practice or group should be documented in your compliance plan and training for all providers should be conducted routinely and monitored through periodic audits. Although you have some autonomy in how you approach compliance, you need to take into account your major payer(s) and the rules they have published when choosing which system to adopt.

The following is a description of the PRS Data point system to determine the appropriate level of service.

The following are considered one (1) point if documented in the record for the visit.

  • Order one more tests from a single category
  • Radiology (70000-79999)
  • Pathology (80000-89999)
  • Medicine (90000-99199)
  • Other diagnostic test with approved medical device
  • Review report or data represented by a single CPT code
  • Review of data from other FDA approved device or source

The following are considered two (2) points if documented in the record for the visit:

  • Direct visualization of an image
  • Extensive review of records from another physician

Data points are added for final level determination

  • 1 point (minimum level 1 or 2),
  • 2 points (limited level 3)
  • 3 points (moderate level 4)
  • 4 points (extensive level 5)

The following table summarizes the PRS system.

Documentation must support data that was reviewed and used in the Medical Decision Making process for that date. This documentation is typically included in the assessment or plan section of the E/M note and will likely reflect that, based on the data reviewed, a decision to treat, observe, maintain or further test is made.

A simple example could be as follows:

“PVR 45ml – continue Tamsulosin “ or
“RBCs present in UA – schedule Cysto”

The following table based on the Marshfield Clinic audit system typically limits the number of points per category to 1 for each CPT section and groups ordering and reviewing together.

One of the Medicare Area Contractors published an audit tool built on the Marshfield Clinic system allowing2 points for the Lab, X-ray and Medicine section categories if 4 more tests from the category were ordered/reviewed. The system also allowed 1 point for physiologic or testing data not separately paid to the physician.

Regardless of which system you have adopted for scoring, it is clear that data review and documentation is a part of the Medical Decision Making process. As we move into an age where data is provided to the physician from sources more directly linked to the patient, we need to adapt the system to categorize new types of information. Information from smart devices, remote monitoring devices, para-professionals and self-administered tests is quickly becoming an essential tool for integrated medical care.

In an attempt to remain consistent and true to the definition of data and adapt to the changing tools and the associated risks, we have adopted a policy that classifies information collected, recorded or manipulated via approved medical device as data. Although this excludes some smart devices such as Apple Watches with blood pressure monitoring, by drawing the line with Medically approved devices, we are more closely mirroring the current scoring systems for data which is primarily based on CPT/HCPCS defined services, tests and procedures. We did not feel that we should exclude all information that could not be identified or reported by a CPT/HCPCS code as coverage for services provided remotely. This is necessary as CPT/HCPCS system does not keep pace with medical practice.

Under this definition we continue to count data identified by CPT codes such as UA, PVR, Uroflow, Doppler, Ultrasound etc., as data when the results are clearly referenced in the medical record. We will also count such information collected via FDA approved devices for vital signs, weight, blood pressure, heart rate, glucose monitoring and at home drug tests recorded and referenced, as Data relative to MDM during the visit. New technologies that have been approved, which we have not yet seen incorporated in medical records that we have reviewed, are anticipated in the near future. A few examples of technology currently under review or approved for home use include: Remote Uroflow data provided via App to the office, remote bladder diary recorded via direct measurement of voiding pattern by an approved device, remote urinalysis tests, and urine output measurement devices. We expect this list to grow in very quickly as telemedicine is increasingly seen as a solution to health care access problems of both acute and chronic care.

PRS encourages the clinician and the office to clearly document and categorize data in the medical record to reflect the amount of work provided for each visit. Adapting our audit and training to the changing practice of medicine may require some additional training and change to medical record templates. We further anticipate that telemedicine will be expanded to accommodate the lack of physicians available to provide face to face care in a timely and cost-effective encounter. Whether the encounter is provided face-to face or via video teleconference or telephone, documenting appropriate test review as data relative to treatment will assist the physician in charging and getting paid for the services they provide.

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Mark N. Painter is a managing Partner of PRS Consulting, LLC, the CEO of PRS, LLC and the Vice President of Coding and Reimbursement Information for Physician Reimbursement Systems, Inc. (PRS). Since co-founding PRS in 1989, Mr. Painter has served as the primary coding resource for the PRS products including Hotlines, Coding Manuals and quick reference tools, the Internet based application and seminars. He has lectured to a variety of groups concerned with health care reimbursement. Mr. Painter's extensive knowledge of physician reimbursement issues has allowed him to assist insurance companies, physicians and their staff members, legal counsel, actuaries, Specialty Societies and consultants on a daily basis. He has serves has an expert to legal counsel, bio device companies and pharmaceuticals. He was a co-chair of the Colorado Clean Claims Task Force, a committee of nationally known industry experts charged with the development of single payment edit database for the state. Mr. Painter is a CPMA. Mr. Painter received his B.A. from Grinnell College at Grinnell, Iowa.