Otolaryngology Coding Alert

Question: For medical decision making (MDM) coding, should you count the order and review of a unique test as one bullet or two?

North Carolina Subscriber

Answer: Though the 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. 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 medical decision making (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.

Tip 4: If the test order at the last encounter was not counted, i.e.: Nature of presenting problems and Risk were used to calculate MDM at that encounter, leaving out Data ordered and reviewed, then the Analysis of the data at the subsequent encounter for that test can be counted (assuming that this is not a test that the practice codes for and bills for separately, i.e., allergy testing and audiology testing)