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!


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