Primary Care Coding Alert

Question: In the article “Start the Year at the Highest Level by Solving These MDM Scenarios,” published in Primary Care Coding Alert volume 23, 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 moderate level of 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, or 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, or 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.