Pediatric Coding Alert

Question: The 2021 office and outpatient evaluation and management (E/M) guidelines for medical decision making (MDM) state that “ordering of each unique test” and “review of each unique test(s)” can be counted toward the amount and/or complexity of data to be reviewed element of MDM. Does this mean our pediatrician can count lab tests when the order goes to our in-house lab and our office receives the reimbursement for the test? And can we also get MDM credit for reviewing and analyzing the tests at a subsequent appointment?

Wisconsin Subscriber

Answer: First, in calculating MDM, a provider or a qualified health care professional (QHP) gets credit for ordering the test regardless of where the test is conducted. If the provider or QHP orders more than one test, each unique test is counted toward the amount and/or complexity of the data to be reviewed element of your MDM calculation.

Keep in mind: Panels such as 80050 (General health panel …) and some tests that have other tests bundled into them count as unique, not multiple, tests.

Second, per CPT^® guidelines, you can only get credit for reviewing and analyzing tests that do not include interpretation and review as a part of the total service package. Or, as CPT^® puts it, “When the physician or other qualified health care professional is reporting a separate CPT^® code that includes interpretation and/or report, the interpretation and/or report should not count toward the MDM when selecting a level of office or other outpatient services.”

So, for example, you can count 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) once as a unique test, but you cannot count the test review, or the interpretation and report, as that is included as part of the 93000 service.