Answers to Evaluation & Management Questions From Webinar Attendees

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aug 28th, 2023

Question:  Can the treating provider refer to another specialty group’s note within the same EHR to count as an external note reference?

The E/M Table allows a point to be given for “Review of prior external note(s) from each unique source*” and the CPT® manual includes an asterisk to indicate they have provided a definition for unique source, as noted below: 

• Unique Source is defined by CPT as, “A unique source is defined as a physician or other qualified health 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.”

Additionally, CPT® provides definitions for the terms “external” and “external physician or qualified health care professional,” to ensure proper application and scoring, as follows:

• 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.”

After careful review of the definitions and guidelines, we can safely say that as long as the note being reviewed meets the criteria of being from a physician or other qualified health care professional (QHP), who is part of another group or specialty or subspecialty, even if they can access the same EHR system, it can be counted as “review of a prior external note(s) from each unique source.” 

One caveat or recommendation, would be that the provider document the unique source and the external note reviewed, and whether anything from that note was relevant to the care of the patient for the purposes of clarity. Consider if the provider had to explain to a judge what was reviewed and why, does the documentation provide the necessary information for such a conversation or would it be lacking? 

Documentation Examples: 

• Reviewed the pulmonologist’s note from the patient’s last encounter with him to confirm medications prescribed and doses.
• Reviewed discharge summary and labs from ABC Hospital to identify changes in treatment or medications and relevant test results.
• Reviewed report from patient’s visit to the emergency department last month at XYZ Hospital.
• Reviewed cardiology consult report from Dr. Sherman, performed two months ago.
• Reviewed medical records from the patient’s past provider when she resided in San Diego.

Question: Can the provider document an independent interpretation if the documentation says, “I agree with the test referenced above in the note” and then the provider documents a diagnosis treatment plan around the findings?

Again, reviewing the language used in the CPT® E/M Table we find a point is allowed under the MDM Data element for Category 2 for “Independent interpretation of test performed by another physician/other qualified health care professional (not separately reported).”

Again, to clarify what an independent interpretation is, the CPT® codebook E/M guidelines further defines it as:

• “Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.”

In other words, the type of test matters, in that it must be a test represented by a CPT code that usually requires a professional interpretation or report. Simple lab tests with a simple lab value and reference range or positive/negative result would not qualify for independent interpretation. A good way to view this is to consider if the type of test being independently interpreted requires a professional interpretation. The guidelines indicate that the provider can simply document the independent interpretation in the encounter note and is not required to document a separately identifiable report of their interpretation. However, we must also consider that “independent” means the provider has reviewed the films or data produced by the test and has documented their own professional interpretation of the test, not just referring back to the original interpretation that came with the test. 

Both of these examples clearly demonstrate the provider personally viewed the images or applicable data (e.g., EKG strips) and documented their own professional interpretation of them in the chart. As such, if the provider ordered the test, they get E/M MDM Data element credit for a test ordered along with credit for the independent interpretation of a test. 

When trying to determine if the documentation meets the scoring criteria for E/M MDM, be sure to carefully review the documentation and compare it with the definitions published in the CPT® coding guidelines.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.