I am in need of some advice on some records I’m reviewing. This is directly related to the "Amount and/or Complexity of Data Reviewed" of the MDM component.

If the Physician notes she performs a "Urine Toxicology Screening", checking for RX compliance, and mentions she personally "reviewed the dipstick herself which provides a preliminary result for the potential of more or more drugs", how many points does this qualify for?

One total, for the review and/or order of clinical labs?
Two total, for the independent visualization of a specimen?
Three total, for ordering/reviewing and also independent visualization?

I’ve seen many conversations about this, but no hard documentation that says truly which one. I’ve researched in Optum’s Evaluation and Management Coding Advisor and it isn’t answered for my scenario. I’ve Googled and can only find opinions, but nothing from bigger reputable sources. If anyone has something in writing I would greatly appreciate it!

Thanks so much!