Gastroenterology Coding Alert

Question: If a lab test is ordered and the review of results must be combined with other criteria to count as one data element in the CPT^® medical decision making (MDM) table, why are there separate bulleted items listed for review of the results and ordering of each unique test for category 1?

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Answer: To fully understand this, it’s important to remember that CPT^® structured Table 2, Levels of Medical Decision Making, to present each MDM level’s required criteria when a particular element (plus at least one other element) is used to select the appropriate evaluation and management (E/M) code. Depending on the level of MDM (straightforward, low, moderate, high), each unique test, order, or document will contribute to the combination of two or combination of three elements of MDM.

As far as tests go, although the order and review of a laboratory test counts as a single data element for MDM selection, sometimes there are circumstances when an order or review of a laboratory test is performed separately.

For example, when results-only tests are downloaded and not reported to the third-party payer for billing purposes, such as those that would be sent over from another physician’s office, the review of the results may be counted as review of a test. In addition, a patient-generated blood-pressure log, reviewed by the physician or other qualified health care professional (QHP), may also be counted as a review of a test for an MDM data element as part of the MDM level selection.

However, when tests are ordered between visits or a standing order exists, a review of new test results during an E/M encounter is counted toward the MDM level at that encounter. During this encounter, new work is performed when test results are reviewed, assessed, and documented; therefore, they will be counted toward MDM level selection if they are related to a problem addressed at this encounter. If a new order is submitted for a future laboratory test or other test (i.e., it is not a standing order), the physician or other QHP would also receive credit toward MDM for the current encounter.