Making Sense of the Three Most Confusing Complexity of Data Categories

August 14, 2023

Based on questions from our clients and readers, there appears to be a lot of confusion about definitions and interpretations of several categories involving “Complexity of Data.” So, in this week’s edition of Coffee & Coding, let’s take a closer look at the three categories that appear to generate the most questions.

1. Assessment requiring an independent historian

We frequently hear questions like: “What constitutes an independent historian?” and “When are they used?” Put simply, an independent historian is someone who can advocate on behalf of a patient unable to communicate for themselves due to factors like age or disability. For instance, a mother, father, grandparent, or guardian can act as an independent historian for a child during a sick visit or physical exam. In the case of an older adult dealing with conditions such as dementia, Alzheimer’s, cognitive decline, stroke, or other impairments affecting memory or speech, an independent historian could be a family member, healthcare proxy, nursing/assisted living aide, or any individual responsible for the senior’s care.

2. Independent interpretation of tests performed by another physician or qualified health care professional

The two most common scenarios in which this category is appropriate are:

  • When a patient from a specialty practice brings their ED/PCP records; and
  • When lab testing and/or imaging are conducted at a facility different from where the patient is receiving care.

One frequent point of confusion: If the physician both orders and interprets the X-ray, then your group can only receive credit for the order, even if the imaging was conducted at a different location. According to the MDM (Medical Decision-Making) guidelines, this would be considered “double-dipping.”

3. Discussion of management or test interpretation

This category—the most confusing of all—applies when the physician discusses patient management or test interpretation with an external physician or other qualified healthcare professional. In other words, this category captures physician-to-physician discussions that extend outside the practice. Typically, this involves communication between the primary care physician (PCP) and an external specialist, such as an orthopedist, an ER physician, or a mental health professional. It’s important to note that discussions involving an external physician or qualified healthcare professional are the ONLY instances where this category can be applied to the medical decision-making process.

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coders@calmwatersai.com!


Download PDF

More Coffee & Coding

ICD-10 updates: What you need to know

Coming October 1: 2024 ICD-10 Diagnosis Changes September 18, 2023 This time of year can be stressful for providers and coders. It is a time when we’re on the lookout for notifications about ICD-10 code updates. Each year, the volume of these changes appears to...

How Communication Makes for Better Documentation

How Better Communication Makes for Better Documentation September 11, 2023 Artificial Intelligence (AI) is only as good as the documentation it reads. But what does that mean? In the realm of doctor pro-fee office billing, if the documentation is unclear, AI cannot...

Coding for Social Determinants of Health

Coding for Social Determinants of Health August 28, 2023 Here’s a sobering thought for healthcare professionals: According to the National Academy of Medicine, medical care accounts for only 10% to 20% of all health outcomes. Social Determinants of Health (SDOH)...

Billing for E/M Services During the Global Period

Billing for E/M Services During the Global Period August 21, 2023 We frequently receive questions about "Global Periods" for surgical procedures. People often ask, "What are the time limits for these periods?" and "To which types of procedures do these post-op periods...

Level 5 Drug Therapy Requiring Intensive Monitoring for Toxicity

Level 5 Drug Therapy Requiring Intensive Monitoring for Toxicity August 7, 2023 We get a number of questions on this topic, and for good reason: It’s complicated! To simplify things a little, let’s start with some common examples of what does NOT qualify for intensive...

Telehealth Visits: Keeping Up with the Latest Changes

Telehealth Visits: Keeping Up with the Latest Changes July 31, 2023 Now that the public health emergency is officially over, some of the coding requirements regarding telehealth visits that were put in place during the COVID-19 pandemic have been revised. To receive...

Billing Wellness Visits Under Medicare, Part III

Billing Annual Wellness Visits Under Medicare, Part III July 24, 2023 Last week, we delved deeper into the second of three types of wellness visits—Annual Wellness Visits (AWVs)—covered by Medicare. Now, let's shift our focus to Subsequent Wellness Visits (along with...

Billing Wellness Visits Under Medicare, Part II

Billing Wellness Visits Under Medicare, Part II July 17, 2023 Last week, we delved deeper into the first of three types of wellness visits—IPPEs—covered by Medicare. Now, let's do the same for the second category: Annual Wellness Visits (AWVs). AWV (Annual Wellness...

Billing Wellness Visits Under Medicare, Part I

Billing Wellness Visits Under Medicare, Part I July 10, 2023 Nobody—and I mean nobody—welcomes an audit from CMS. That means taking extra care when assigning E/M codes to outpatient visits covered by Medicare. And with that in mind, the following three editions of...

Subscribe to Our Weekly Coffee & Coding Newsletter