General Surgery Coding Alert

Question: If the surgeon bills an E/M visit based on medical decision making (MDM), not time, can they consider test results received on different dates of service toward the complexity or amount of data reviewed and analyzed that counts as an element of MDM?

Missouri Subscriber

Answer: Yes, you can count the test result review as part of the MDM for the E/M service as long as you’re not reporting the test review separately. You should count the test order and review as data for the encounter in which the test was ordered, even though it may not have occurred on the date of the encounter itself.

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].To be clear, the test order and review count as one data point, not two.

Caution: 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.”