The work that is invisible unless you write it down
The data column rewards engaging with information: ordering and reviewing tests, pulling outside records, talking to another clinician, and interpreting imaging yourself. None of it scores unless it is documented, which is why this is the element most often left blank.
- Credit comes from reviewing tests, external records, talking to other clinicians, and independently interpreting imaging.
- Each category counts separately; document what you reviewed and from where.
- Your own read of an image, distinct from the formal report, is one of the most commonly missed data points.
This is the second of the three MDM columns, and it is the one that most often rewards work that goes unrecorded. It asks what you reviewed in order to make your decision. It favors clinicians who actively engage with data: not just ordering tests, but reviewing results, reading outside records, coordinating with other clinicians, and interpreting imaging themselves. The overview of medical decision making shows how this column fits with the other two.
The Four Levels of Data Complexity
- Straightforward: minimal or no data.
- Low: a limited amount; any two category 1 items, such as tests ordered, results reviewed, or external notes reviewed, or use of an independent historian.
- Moderate: review external records and order or review tests, or obtain independent interpretation of results, or have an independent discussion about the patient's management with an external physician or other qualified professional.
- High: an extensive amount; combine review of external records, independent interpretation of tests, and discussion with external clinicians.
The Three Things This Column Counts
Underneath the tiers, the column is really tallying three kinds of effort. It helps to think in these terms rather than memorizing the grid.
Tests and records. Ordering or reviewing each unique test counts, as does reviewing outside records or getting history from someone other than the patient. Note that ordering a test already includes its later review: you get the credit on the day you order it, and you cannot claim a second point for reviewing that same result at the next visit.
Discussion with another clinician. An independent discussion about the patient's management with an external physician or other qualified health professional counts, provided it is a genuine two-way exchange about this patient rather than a curbside formality. Document who you spoke with and about what.
Independent interpretation. Personally interpreting a study that another provider ordered or performed, and that you are not separately coding, is its own credit. This is the one most clinicians get wrong, so it is worth a section of its own.
Independent Interpretation: A Point Most Clinicians Misunderstand
One data element is worth getting exactly right, because it is both valuable and commonly misapplied: independent interpretation of a test. You earn this credit only when you personally interpret a study that someone else ordered or performed, and that you are not separately coding for. A common example outside imaging: an electrocardiogram is performed and formally read by another physician who codes for that interpretation, and then you review the tracing yourself and document your own read. Because the order and the coded interpretation belong to another provider, your independent interpretation counts. The same logic applies to any study with a separate professional read you are not coding, such as an outside imaging study you interpret yourself. Note that this is interpretation, not review: a routine lab result has no separate professional read to interpret, so reviewing it counts under ordering and reviewing tests rather than here.
Two limits follow from this. You cannot claim independent-interpretation credit for a test you ordered and are interpreting yourself, nor for one you are coding separately. And ordering a test already includes reviewing it: you get the data credit on the day you order it, and you cannot claim a fresh point for reviewing that same result at the next visit. When you do take independent-interpretation credit, document who ordered the study, the date, and your own interpretation; a formal radiology-style report is not required, but your read must be recorded.
What to Write for the Data Column
Name the data you reviewed, specifically. "Reviewed today's in-office HbA1c and basic metabolic panel. Reviewed outside cardiology note from three months ago." That is test review plus external records, which is moderate complexity for this column. When you interpret imaging yourself, say so and give your read. When you discuss a patient with another clinician, name them and the question. Vague phrases like "labs reviewed" leave credit on the table; specifics capture it.
Sources and Further Reading for This Chapter
- American Medical Association, Evaluation and Management (E/M) Coding. https://www.ama-assn.org/practice-management/cpt/evaluation-and-management-em-coding
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician