Pulmonology Coding Alert

Question: If a provider is billing an outpatient E/M code based on medical decision making (MDM), not on time, can they count the review of test results they ordered on the previous encounter date toward the amount or complexity of data to be reviewed and analyzed element of MDM of the current encounter?Utah Subscriber

Answer: CPT^® guidelines state, “The amount and/or complexity of data to be reviewed and analyzed … includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.… It includes interpretation of tests that are not separately reported. 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” [italics added for emphasis].

When you order a test, the interpretation is assumed to be part of the work of that test. You can’t count the order and review separately for different encounters. You can count the order in the MDM for the first encounter (when the test is ordered) as long as the test is not being separately billed. But you cannot count anything for that test in the MDM of the second encounter.

Coding alert: When billing office/outpatient E/M codes based on time, test analysis is not subject to the same guidelines. Per CPT^® guidelines, “ordering medications, tests, or procedures” and “independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver” can be counted toward the total time of the encounter, but only “the time personally spent by the physician and or other qualified health care professional(s) assessing and managing the patient on the date of the encounter [italics added for emphasis] is summed to define total time.”