EM Coding Alert

Question: If a provider is billing based on medical decision making (MDM), not on time, can he count test results he has received on a different date of service toward the amount or complexity of data to be reviewed and analyzed element of MDM?

Missouri Subscriber

Answer: CPT^® guidelines state: “The amount and/or complexity of data to be reviewed and analyzed … includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.… It includes interpretation of tests that are not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter” [italics added for emphasis].

So, providing you are not reporting the test review separately, this means you would count the test order along with its review as data for the encounter for which the test was ordered, even though it may not have occurred on the date of the encounter itself.

Coding alert: When billing office/outpatient E/M codes based on time, test analysis is not subject to the same guidelines. Per CPT^® guidelines, “ordering medications, tests, or procedures” and “independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver” can be counted toward the total time of the encounter, but only “the time personally spent by the physician and or other qualified health care professional(s) assessing and managing the patient on the date of the encounter [italics added for emphasis] is summed to define total time.”