Pediatric Coding Alert

Question: How would you count the amount/complexity of data in the following scenario?

On the first visit, the pediatrician orders a positron emission tomography (PET) scan. The insurance denies the scan but approves two CT scans of the abdomen/pelvis and chest, which the pediatrician orders but not at a visit. The patient then returns for a second visit at which the pediatrician reviews the test.

Should I not count the review at all, as insurance changed the test to other, additional tests? Should I count the review as one test, as that was the original order? Or should I count the review as two tests?

AAPC Forum Participant

Answer: Even though your pediatrician ordered a test that was denied, and the insurance company changed that order to two tests, these facts alone don’t tell you how to count the data points for this particular element of medical decision making (MDM) in this encounter. The issue here is simply that your pediatrician analyzed two tests as a part of a visit, regardless of the circumstances behind the ordering and the fact that the order was placed outside the first visit. Your pediatrician should therefore get credit for that work.

Why? CPT^® guidelines state that “tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.” In this situation, then, the abdomen/pelvis and chest CT scans should be counted as two unique tests.