Otolaryngology Coding Alert

Question: If the provider orders lab work and a week later goes over the results with the patient at a follow-up visit, do I count the effort and work involved in the review toward medical decision making (MDM)? The lab order was counted as part of the prior visit’s MDM.

Louisiana Subscriber

Answer: No, you should only count data, which in this case is the lab work, once, usually at the encounter when it was ordered. Per CPT^® guidelines, “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.”

Note: If your otolaryngologist ordered labs in between visits or a different provider ordered the lab work and your provider is reviewing that data as part of the MDM workup for the patient, you may be able to count the lab results review toward MDM for that encounter.

When the provider orders a diagnostic test and reviews the results — that day, a day later, or at a subsequent visit — you should not give them credit for reviewing the test results that they ordered. “It is assumed that the physician or other QHP [qualified health care professional] would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test,” per CPT^® Assistant (November 2020).

“If a new diagnosis and plan of care are developed as a result of the lab result, the diagnosis can count towards the Problem in the subsequent visit’s MDM, and the new plan of care might impact the risk level so that the outcome from this encounter, the diagnosis and planned treatment supporting MDM will determine the [evaluation and management] E/M level. If the results of the prior testing prompt the ordering of any subsequent testing, the ordering of subsequent testing can also be counted as data in this visit’s E/M level calculation. Keep in mind the E/M MDM only needs two of the three of Problem, Data, and Risk, so the diagnosis and plan of care give the provider two of three elements, the Problem and Risk,” notes Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare Solutions in Tinton Falls, New Jersey.