# MDM - review/order of test in medicine section (9xxxx) of CPT



## scicchitanoa (Oct 10, 2012)

Hello fellow coders! Can you please share your opinions regarding calculating Medical Decision Making (MDM) level using the Marshfield Clinic Score sheet/Audit tool?

My question is specific to *Table B – “Review and/or order of test in the medicine section of CPT (e.g. CPT 9xxxx series)”  *

Do you interpret the above to mean…. 

*A)* You could give 1 point when a physician reviews and/or orders an *actual ‘test’ *that is listed in the 9xxxx series (ex: EKG, EEG, EMG, Sleep medicine testing)? 

*OR*​
*B)* You could give 1 point when a physician orders anything in the 9xxx series even if the physician orders something list in the 9xxx series that is *not an actual ‘test’ *(ex: hydration and infusion are both listed in the 9xxxx but these are not “tests”, also nebulizer treatment is listed in 9xxxx but this is a ‘treatment’ not a ‘test’) 

Thanks! Ashley


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## CBaer (Oct 13, 2012)

Based on the documentation guidelines it states:  diagnostic service (test or procedure) I consider infusion a procedure therefore i would give credit.

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.
Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who
prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.
DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented.


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## FTessaBartels (Oct 22, 2012)

*Infusion is NOT diagnostic*

To get credit for data order/reviewed the procedure must be DIAGNOSTIC.

Infusions are therapeutic, NOT diagnostic.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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