Question: How is reviewing 3 documents from an admission credited?
More specifically, If the physician reviews records from a recent hospital admission and the records include 1) a discharge summary and 2) a report for an MRI and 3) a report for an ultrasound, would these count as one point under “review of prior external notes from each unique source” or three points (review of one document and two unique test results)?
Answer: The American Medical Association answers this question in two places, the CPT® book itself and in a clarification in the CPT® Assistant, September, 2022.
From the CPT® book (2026 Professional Ed., p. 12)
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.
September 2022, CPT® Assistant:
Question: A physician or other qualified health care professional (QHP) reviews an electronic medical record (EMR) that contains a computed tomography (CT) scan report, an operative note, and a pathology report that came from three different specialties within the same hospital. Is this EMR considered a single unique source because all documents are from the same entity (the hospital) or three independent unique sources of data because they came from three different specialties?
Answer: Review of outside records from a single source, in this case, hospital records, is counted as one element. A unique source is defined as a physician or other QHP 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 medical decision making (MDM). Note that if it were medically necessary for the physician or QHP to independently review the CT images, then this could qualify as meeting Category 2, Independent Interpretation of Tests, under the MDM element of “amount and/or complexity of data to be reviewed and analyzed.”
The answer to the question: reviewing the discharge summary, the report of the MRI, and the report of the ultrasound are credited as one data point. If it was medically necessary for the physician to review a diagnostic image and perform an independent interpretation, that is credited separately.