Primary Care Coding Alert

Problem complexity: Depending on specifics, medical decision making (MDM) could be either low or moderate. If the patient is experiencing systemic symptoms (for example, the patient had severe respiratory problems or is experiencing persistent chest pressure or pain), then you could assign a moderate level for this element, since you would have one acute illness with systemic symptoms. However, if the symptoms are mild, then you would view this as an acute, uncomplicated illness, and the level for this element would be low. Given the provider’s treatment plan, a low level for this element would seem the most likely.

Data reviewed: Here, the PCP ordered and reviewed a single, unique test — in this case, most likely 86328 (Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])).

The test order and review in this situation would count as one data element since it’s the same test being ordered and reviewed — you should not count it once as an order and again as a review of results. As such, this correlates to straightforward MDM.

Risk of patient management: As the PCP’s instructions are for home care and isolation, this element level would only rise to minimal.

Putting it all together: MDM requires two of the three elements to be met at the designated level. In this case, it appears the data review and risk are both minimal, which supports only straightforward MDM. Thus, if coding based on MDM, the encounter would appear to only support 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …). The alternative is to report the level of service based on total time spent on the date of the encounter.

Don’t forget: You can count the 86328 test order as an MDM element and still bill the test separately. As the AMA clarifies, “Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM … may be counted as ordered or reviewed for selecting an MDM level,” and that “any specifically identifiable procedure or service (i.e., identified with a specific CPT^® code) performed on the date of E/M services may be reported separately” (www.ama-assn.org/system/files/cpt-corrections-errata-2021.pdf).

Also, as 86328 is a Clinical Laboratory Improvement Amendments (CLIA)-waived test, you will need to append QW (CLIA waived test) to the 86328 before submitting your bill. You must also have a CLIA certificate of waiver for your practice to perform the test (See www.cms.gov/files/document/mm12557-addition-qw-modifier-healthcare-common-procedure-coding-system-hcpcs-code-86328.pdf).