There has been a great deal of confusion regarding how to count tests/procedures for purposes of coding office visits based on medical decision making (MDM), and the College coding experts have examined these areas of confusion in detail. Based on our review, we have updated our recommendations concerning how to factor in ordering and analysis of tests when using MDM to select an E/M level.
- If the professional interpretation of tests ordered is separately reportable by the physician reporting the evaluation and management (E/M) service, the ordering of the test is not included in determining the level of E/M service. For example, interpretation of skin test results is part of the skin testing code and would not be counted to determine the level of E/M service.
Note: Similarly, for purposes of selecting an E/M code based on time, physicians may not count time spent performing other services that are separately reportable.
- Tests that are results only – tests that do not need separate interpretation – may be counted as ordered/reviewed for determining an MDM level, even if the test was reported by the physician performing the office E/M. However, these tests cannot be counted as an independent interpretation. Examples of results-only tests include dipstick urinalysis tests, rapid strep tests, and complete blood count and would also include IgE tests such as ImmunoCap.
- When tests are ordered during an encounter, the tests are counted in that encounter. When they are ordered outside of an encounter, the tests may be counted in the subsequent E/M encounter in which they are analyzed.
For additional information, please refer to the AMA’s CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes.
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