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reserved.
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe
exacerbation or progression of a chronic illness or severe side effects of treatment that have significant
risk of morbidity and may require hospital level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with
systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or
progression or side effects of treatment, that poses a threat to life or bodily function in the near term
without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe
respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self
or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.
Analyzed: The process of using the data as part of the MDM. The data element itself may not be subject
to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or
treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they
are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an
encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order,
each new result may be counted in the encounter in which it is analyzed. For example, an encounter that
includes an order for monthly prothrombin times would count for one prothrombin time ordered and
reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test
in that subsequent encounter. Any service for which the professional component is separately reported by
the physician or other qualified health care professional reporting the E/M services is not counted as a
data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining
the level of MDM.
Test: Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg,
basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests
is defined in accordance with the CPT code set. For the purposes of data reviewed and analyzed, pulse
oximetry is not a test.
Unique: A unique test is defined by the CPT code set. When multiple results of the same unique test (eg,
serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that
have overlapping elements are not unique, even if they are identified with distinct CPT codes. For
example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and
platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct
group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique
source counts as one element toward MDM.
Combination of Data Elements: A combination of different data elements, for example, a combination of
notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be
summed. It does not require each item type or category to be represented. A unique test ordered, plus a
note reviewed and an independent historian would be a combination of three elements.
External: External records, communications and/or test results are from an external physician, other
qualified health care professional, facility, or health care organization.
External physician or other qualified health care professional: An external physician or other qualified
health care professional who is not in the same group practice or is of a different specialty or subspecialty.
This includes licensed professionals who are practicing independently. The individual may also be a
facility or organizational provider such as from a hospital, nursing facility, or home health care agency.