Pulmonology Coding Alert

Question: The Marshfield Clinic's audit tool awards two credits for independent visualization of an image, tracing or specimen itself (not simply review of a report). The tool also awards one credit for ordering a diagnostic test. When a pulmonologist orders a test (such as an electrocardiogram) and personally reviews the tracing on the same day, would he be awarded credit for both the order (1 credit) and the personal review (2 credits)?


California Subscriber


Answer: Some coders and auditors use this tool to help determine the level of medical decision-making for selecting an E/M service code. Although Medicare did not create or issue the tool, CMS has offered guidelines regarding your question.


CMS says: The order and personal review are two separate activities. If you order the electrocardiogram (ECG), you might not get to review it. If you do review it or look at the tracing, and make judgments, then documenting this activity should allow you to have credit for both ordering and reviewing it (not just reading a report).

What this means: This clarification is huge for pulmonologists who personally review their own diagnostic testing, such as x-rays and ECGs.

Caution: Be careful not to double-dip. When a physician performs a test that requires a review of the image for a separately billable interpretation, some payers will not award 2-point credit in medical decision-making  for this since the physician is being paid for the personal review. Thus, he only receives one point for the order.

Let's break it down: You should understand that when it comes to the audit tool's complexity section, you only need four credits in the data section to achieve a "high" level of medical decision-making, assuming that at least one of the other complexity section elements (diagnoses/treatment options or table of risk) also supports this level of complexity.