Orthopedic Coding Alert

Question: I am still getting used to the new rules for office/outpatient evaluation and management (E/M) services. For medical decision making (MDM) coding, should you count the order and review of a unique test as one bullet or two?

Montana Subscriber

Answer: Though the new guidelines for ordering, reviewing, and/or interpreting tests are still a little unclear, CPT^® does state that “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.”

This seems to suggest that both ordering and reviewing a unique test should only be counted as one bullet in category 1 of the limited, moderate, and high levels of amount and/or complexity of data to be reviewed and analyzed because, as you say, a provider ordering a test is also expected to review it.

The most up-to-date advice on MDM bullet counting can be summarized in these three tips:

Tip 1: If a test is ordered, do not count that same test again for reviewing it in the same encounter or a subsequent encounter. Instead, count each unique test as one bullet in category 1 of the limited, moderate, and high levels of amount and/or complexity of data to be reviewed and analyzed.

Tip 2: If you separately bill a test with a CPT^® code that includes interpretation and report, you cannot count it at all toward the amount and/or complexity of data MDM element (though the AMA and CPT^® have yet to fully clarify if this is also true of tests where the CPT^® code does not specify if the service includes interpretation and report).

Tip 3: If your provider is not ordering but interpreting (meaning viewing and interpreting the actual test images/ readings, and not just a report or lab results) a test performed by a different provider, that would satisfy category 2 of the MDM data element at the moderate or high level unless the provider is billing a CPT^® code for an independent interpretation of the test.

Remember: The above advice applies only to office/outpatient E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.). The new rules don’t apply to other E/M code sets (hospital inpatient, critical care, hospital observation, etc.).