Primary Care Coding Alert

Question: Two weeks ago, a patient saw one of our providers who orders labs. The patient came back today without having the labs done. The provider re-evaluated the patient and educated them on the need for getting the labs done. Should I count this order of the unique tests again at this visit?

AAPC Forum Participant

Answer: Whether you can count the labs or not at this encounter really depends on what your provider actually did. If the provider spent the time reminding the patient about the importance of the lab work and wrote a duplicate order for the same labs from the previous encounter, then you probably cannot count the order toward the medical decision making (MDM) level for the encounter, since there was no MDM involved in writing the duplicate order (i.e., all the MDM occurred when the provider wrote the order the first time).

However, if the provider has documented that the patient has been re-evaluated and that the labs are still needed due to the patient’s condition (i.e., the provider has documented that they went through the MDM process again in re-issuing the orders), then you should probably be able to count the unique test order(s) for this encounter.