Pediatric Coding Alert

Question: In the answer to question 2 in “Take This Quiz, See if Your 2021 MDM Knowledge is on the Level,” published in Pediatric Coding Alert volume 24, number 1, you counted the ordering and reviewing of a unique test as two bullets out of the four bullets in category 1 of the amount and/or complexity of data to be reviewed and analyzed. Can you please clarify this, as I believe it is expected that if a provider orders a test, they will look at the results and make a decision based on the reviewed results — in other words, ordering and reviewing a unique test should only count as one bullet, not 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.

However, at the time of going to press, the AMA or CPT^® Assistant have yet to fully explain how to count tests. With that in mind, our best advice at this point 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.