Wiki 2021 E/M Guidelines - Cat 2 Ordering Unique Tests for labs

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Anduiza05

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Hello,

I am currently training my Urology doctors on the new E/M changes for 2021. Can someone tell me what they are saying to their doctors regarding Cat 2 "Amount and/or Complexity of Data to be Reviewed and Analyzed?

My question is related to the ordering of unique tests. In order to bill for a moderate level (99214 or 99204) the chart below states that they can order and review a unique test (lab) and receive credit for both.

An example, doctors order a UA lab test and review on the same day, that would give them 2 points one for the order and one for the review?

Also, do they only need to meet one of the 3 categories to meet the data required for Moderate? I am not sure if I am interpreting this correctly and my doctors are in disbelief that it will be this easy to bill for a moderate level.

Moderate 99214 of 99204
(Must meet the requirements of at least 1 out of 3 categories)"
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) or
Category 2: Independent interpretation of tests
"• Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported); or"
Category 3: Discussion of management or test interpretation (Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)
 
2
Anduiza05 said:
Hello,

I am currently training my Urology doctors on the new E/M changes for 2021. Can someone tell me what they are saying to their doctors regarding Cat 2 "Amount and/or Complexity of Data to be Reviewed and Analyzed?

My question is related to the ordering of unique tests. In order to bill for a moderate level (99214 or 99204) the chart below states that they can order and review a unique test (lab) and receive credit for both.

An example, doctors order a UA lab test and review on the same day, that would give them 2 points one for the order and one for the review?

Also, do they only need to meet one of the 3 categories to meet the data required for Moderate? I am not sure if I am interpreting this correctly and my doctors are in disbelief that it will be this easy to bill for a moderate level.

Moderate 99214 of 99204
(Must meet the requirements of at least 1 out of 3 categories)"
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) or
Category 2: Independent interpretation of tests
"• Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported); or"
Category 3: Discussion of management or test interpretation (Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)
Click to expand...
Each unique test is counted once (either order or review). CPT states, "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."
Laboratory test orders or results are counted whether performed in-house or sent out to a laboratory because these codes are valued only to include the cost of the test and not physician interpretation and report. A physician does not get credit for ordering or reviewing results of tests when reporting a code that includes interpretation and report (e.g., voiding cystourethrogram). "When the physician or other qualified health care professional is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report should not count toward the MDM when selecting a level of office or other outpatient services."

For 99204 or 99214, 1 of the 3 categories must be met. 2 of 3 of the same categories must be met for 99205 or 99215.

I hope that helps.
Cindy
 
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Gator said:
So, if we order 4 different labs (we draw and send out) that each have their own CPT code (not part of a panel), that counts as 4 unique tests as long as we are sending them out and not processing them at in-house lab? If we were billing the CPT for the lab no count as we get reimbursed when we bill the CPT code. I listened to a webinar that stated 1 blood draw for multiple labs only counts as 1.
Click to expand...
Yes, 4 unique tests, per the current 2021 MDM definition for outpatient 99202-99215.
Pre 01/01/2021, you would count labs (no matter how many) as 1 point.
The webinar either was old, or the presenter did not understand the change. Or was addressing other E/M's that the definition hasn't changed.
 
1
natashalage said:
Could someone tell me please if MD orders 3 unique test (EKG, X-ray, Lab. MD does not bill for them), will it meet the requirements of Category 1 from the below:
Moderate 99214 of 99204
(Must meet the requirements of at least 1 out of 3 categories)"
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) or... (copied from above)
Thank you very much.
Click to expand...
That is correct. Each order or review of results of a test represented by a unique CPT code is counted as long as the test/study was not performed and reported by the physician. There is no requirement that the combination of 3 unique tests come under different bullets (e.g., no requirement that you order 1 test, review 1 test, and have an independent historian or review an external record). CPT Assistant of September 2020 clarifies this.

Physicians cannot count the order and review of the same test (e.g., count order of an ECG at this visit and count review of the results at the next visit). Physicians cannot receive credit under data for any test that they perform and interpret.

Key guidelines:
The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately.
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.

I hope that helps.
Cindy
 
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To my understanding, if they are billing for it , say a Urinalysis/ Dip stick done in the office, they cannot include that in the MDM because they are billing for it, no double dipping per say. Now, on the other hand, if they are ordering a U/A and C&S ,they could count that under category 2 as ordered. Each unique test is counted as one (EKG, CHEST X-ray, CBC, TSH, etc. and if any of these tests are not separately reported, they fall under the "ordering of each unique test).
And yes, only one out of the 3 categories need to be met to fall under Moderate MDM. The same rule applies as before , two of the three elements for that level of decision making must be met or exceeded.
 
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Could you please tell me if MD is ordering 3 unique tests (like EKG, Lab, X-ray), does it meet the requirements of Category 1?
"Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:.. " pls see above.
Thank you in advance.
 
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lcolborn said:
To my understanding, if they are billing for it , say a Urinalysis/ Dip stick done in the office, they cannot include that in the MDM because they are billing for it, no double dipping per say. Now, on the other hand, if they are ordering a U/A and C&S ,they could count that under category 2 as ordered. Each unique test is counted as one (EKG, CHEST X-ray, CBC, TSH, etc. and if any of these tests are not separately reported, they fall under the "ordering of each unique test).
And yes, only one out of the 3 categories need to be met to fall under Moderate MDM. The same rule applies as before , two of the three elements for that level of decision making must be met or exceeded.
Click to expand...
Hi so if my doctors order the UA and review the results in the office they can not receive any credit for that order or review?
 
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Cynthia Hughes said:
Each unique test is counted once (either order or review). CPT states, "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."
Laboratory test orders or results are counted whether performed in-house or sent out to a laboratory because these codes are valued only to include the cost of the test and not physician interpretation and report. A physician does not get credit for ordering or reviewing results of tests when reporting a code that includes interpretation and report (e.g., voiding cystourethrogram). "When the physician or other qualified health care professional is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report should not count toward the MDM when selecting a level of office or other outpatient services."

For 99204 or 99214, 1 of the 3 categories must be met. 2 of 3 of the same categories must be met for 99205 or 99215.

I hope that helps.
Cindy
Click to expand...
IMPORTANT CORRECTION to my post above.
The AMA says you cannot count any test toward your data if a CPT code exists for the test and you could separately report it. An organization that I work with had previously receiving conflicting advice that the determining factor was whether or not a test had physician work value but instead, CPT prohibits counting tests that the physician may report separately to discourage physicians from ordering unnecessary tests to raise the level of E/M service. Only count a test or study in the amount and/or complexity of data when another entity will report the code for the test. My apologies for posting advice that is in error in my previous response.
 
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Could someone tell me please if MD orders 3 unique test (EKG, X-ray, Lab. MD does not bill for them), will it meet the requirements of Category 1 from the below:
Moderate 99214 of 99204
(Must meet the requirements of at least 1 out of 3 categories)"
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) or... (copied from above)
Thank you very much.
 
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Anduiza05 said:
Hi so if my doctors order the UA and review the results in the office they can not receive any credit for that order or review?
Click to expand...
As I understand, if your doctors bill for the taking of the UA or the interpretation of the results of the UA then it is not counted towards MDM, if they order a UA and review the imaging of an ultrasound performed prior then the doctor receives two points.
 
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I have an additional question. If the doctor's are reviewing the same tests again (MRI, etc) that they have reviewed on a previous visit, does that count?
 
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Question on data. Here is my example:

Category 1 Any combination of 2 from the following:
  • Review of prior external notes from each unique source
  • Review of result(s) of each unique test
  • Ordering of each unique test
If you reviewed a CBC and a BMP does that count as 2 or does it have to be one from each category?
 
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CBC and BMP counts as 2 and already met the category 1, and does not have to be one from each sub category.
Just an additional info , if the test are ordered by the same provider, they count as test ordered in the MDM from that encounter, and when the patient comes back for their results, the review of results cannot be counted in the MDM grid. Per CPT book , " 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".
 
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So, if we order 4 different labs (we draw and send out) that each have their own CPT code (not part of a panel), that counts as 4 unique tests as long as we are sending them out and not processing them at in-house lab? If we were billing the CPT for the lab no count as we get reimbursed when we bill the CPT code. I listened to a webinar that stated 1 blood draw for multiple labs only counts as 1.
 
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I also am asking because I listened to a webinar that stated it didn't matter how many labs, it was only worth 1. Does anyone have this is writing?
 
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KaylaRieken said:
I also am asking because I listened to a webinar that stated it didn't matter how many labs, it was only worth 1. Does anyone have this is writing?
Click to expand...
Page 14 in my CPT book, states each unique test, order or document is counted. Each lab would be considered a unique test unless it’s part of a panel.
509359A7-9C1D-47A7-B428-3B983454CA73.jpeg
 
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Going back to what Gator said above, if we order 4 labs but we have them done in our own lab and we bill for them, can we still get the 4 points for ordering them? I have read that we can get the points.
 
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Cynthia Hughes said:
Each unique test is counted once (either order or review). CPT states, "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."
Laboratory test orders or results are counted whether performed in-house or sent out to a laboratory because these codes are valued only to include the cost of the test and not physician interpretation and report. A physician does not get credit for ordering or reviewing results of tests when reporting a code that includes interpretation and report (e.g., voiding cystourethrogram). "When the physician or other qualified health care professional is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report should not count toward the MDM when selecting a level of office or other outpatient services."

For 99204 or 99214, 1 of the 3 categories must be met. 2 of 3 of the same categories must be met for 99205 or 99215.

I hope that helps.
Cindy
Click to expand...
Cindy, thank you for posting this information. I am seeing this everywhere, but only as quoted text. I have a client who will not accept this without seeing it straight from the AMA or CPT. Do you have a link you could share or possibly steer me in the right direction? Thank you again.

William
 
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william.hale@taskforcebpo.com said:
Cindy, thank you for posting this information. I am seeing this everywhere, but only as quoted text. I have a client who will not accept this without seeing it straight from the AMA or CPT. Do you have a link you could share or possibly steer me in the right direction? Thank you again.

William
Click to expand...
If you look at the AMA table for EM 2021, you can see this in the purple box under " Amount and/or Complexity of Data to be Reviewed and Analyzed"

"*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below."

 
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If we bill for the labs, can we still get points for ordering them? I understand we do not get points for ordering xrays when billing for them. (which I don't understand why you can do one and not the other)
 
0
Correct me if I am wrong. Any lab, xray, EKG etc that we are billing for with a separate CPT can not be included in the elements of MDM? The ordering and interpretaion of the test is already built into the cpt (CBC 85025) you are billing? Uhg.
 
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Yes, please help! I have same question.... So, you cant use points for ordering tests/xrays-when they are done in office and we bill for them? I understand we cant use review of tests but not ordering either???
 
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This was from an email regarding a recent webinar for Noridian:

"Dear Attendee:

In reviewing some of the questions many of you still are wondering about the data aspects of ordering test and how to count when using the MDM for selection.

Clarifying answers on when you can count the order(s)

CPT says: On page 14 of the CPT book under MDM: when you are not billing separately for the test/or procedure

The amount and/or complexity of data to be reviewed and analyzed. These data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or inter-professional communications that are not reported separately and interpretation of tests that are not reported separately. 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.

The AMA is consistent in this instruction. If you order a diagnostic test, say a CBC at a patient visit, reviewing the results that day, or, a day later, or at the subsequent visit, it is part of the order. When the patient returns to the office two weeks later, you do not get credit for reviewing the CBC results that you ordered. Count the data for the test once, at the encounter when it was ordered.

The CPT Assistant, (AMA publication) November, 2021, page 5: “It is assumed that the physician or other QHP would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test. The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately. (This quote is from the CPT book).The intent of the AMA was not to allow MDM credit for tests that are separately reported by the physician/medical practice. if you ( or the collective you) bills for the test(s) , you don’t credit the order or reviewing the results in the MDM."
 
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natashalage said:
Could someone tell me please if MD orders 3 unique test (EKG, X-ray, Lab. MD does not bill for them), will it meet the requirements of Category 1 from the below:
Moderate 99214 of 99204
(Must meet the requirements of at least 1 out of 3 categories)"
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) or... (copied from above)
Thank you very much.
Click to expand...
Don't know if you got a direct answer for this or not but my understanding after much review is that, yes, you have now fulfilled the requirement for Category 1 by ordering 3 unique tests that the MD does not bill for. It is confusing because it states "combination" of 3 but then at the top of the MDM grid it states ""*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below". But so far, I have continually read and heard that EACH unique test counts and if you have 3 unique tests ordered then you fulfill category 1. Of course, that isn't to say that can change!

I did also find this in CPT Assistant: 1612988141570.png
 
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Anduiza05 said:
Hi so if my doctors order the UA and review the results in the office they can not receive any credit for that order or review?
Click to expand...
I disagree. The guidelines state "the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M when reported separately." No where in there does it say order. The provider still had to use MDM to determine WHICH test to run, wether he is billing for it or not. It also says "When the physician or other QHCP is reporting a separate CPT code that includes interp and/or report, the interp and/or report should not be counted in the medical decision making..." So if we order and bill one lab on 01/01/21, and bring them back to review the results on 01/03/21, I give credit for 1 for the order on 01/01/21. On 01/03 21 I give 0 credit.
 
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Ordering of tests has presented quite the argument around here. Some feel that if the physician recommends a test or a lab but the patient declines then they are still entitled to count it as Ordering a test. I have issues agreeing with that. Is their any published information that either supports or disqualifies this mode of thinking?
 
0
Also from the AMA guidelines.
The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriateCPT code and, if required, with modifier 26 appended.
 
0
1-Does a hearing test or tympanometry if performed in our office qualify as a unique test? 92557- ordered by our physician/performed in our office under physician supervision and reviewed by our physician. Can we count that as unique test ordered and unique test reviewed?
2-CT ordered by our physician, performed by our physician in office, does this qualify as unique test ordered & unique test reviewed?
 
0
Cynthia Hughes said:
That is correct. Each order or review of results of a test represented by a unique CPT code is counted as long as the test/study was not performed and reported by the physician. There is no requirement that the combination of 3 unique tests come under different bullets (e.g., no requirement that you order 1 test, review 1 test, and have an independent historian or review an external record). CPT Assistant of September 2020 clarifies this.

Physicians cannot count the order and review of the same test (e.g., count order of an ECG at this visit and count review of the results at the next visit). Physicians cannot receive credit under data for any test that they perform and interpret.

Key guidelines:
The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately.
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.

I hope that helps.
Cindy
Click to expand...

Hi, Cindy.

So just to confirm,

1-Does a hearing test or tympanometry if performed in our office qualify as a unique test? 92557- ordered by our physician/performed in our office under physician supervision and reviewed by our physician. Can we count that as unique test ordered, and unique test reviewed?

2-CT ordered by our physician, performed in-office, same day, by our physician, and interpreted by the same ordering physician, does this qualify as unique test ordered & unique test reviewed?

Thank you,
Nicole
 
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nicole@ent-sd.com said:
Hi, Cindy.

So just to confirm,

1-Does a hearing test or tympanometry if performed in our office qualify as a unique test? 92557- ordered by our physician/performed in our office under physician supervision and reviewed by our physician. Can we count that as unique test ordered, and unique test reviewed?

2-CT ordered by our physician, performed in-office, same day, by our physician, and interpreted by the same ordering physician, does this qualify as unique test ordered & unique test reviewed?

Thank you,
Nicole
Click to expand...
Hi Nicole,

Just seeing your post so sorry for the delay. CPT states, "Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM."

1. When your physician orders and bills for 92557 or any other audiologic study, the service includes interpretation and report as stated in the CPT guidelines for audiology codes, so the hearing test is separately reported and not counted toward the MDM data element.
2. When the physician (or a physician of the same group practice and same specialty) is billing for the interpretation and report of the CT, that test does not count toward the data element.

Only tests that require no professional interpretation (eg, urinalysis or influenza tests) count toward the data element when billed because there is no interpretation and report included in the value assigned to the test code.

I hope that helps.
Cindy
 
0
Cynthia Hughes said:
Hi Nicole,

Just seeing your post so sorry for the delay. CPT states, "Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM."

1. When your physician orders and bills for 92557 or any other audiologic study, the service includes interpretation and report as stated in the CPT guidelines for audiology codes, so the hearing test is separately reported and not counted toward the MDM data element.
2. When the physician (or a physician of the same group practice and same specialty) is billing for the interpretation and report of the CT, that test does not count toward the data element.

Only tests that require no professional interpretation (eg, urinalysis or influenza tests) count toward the data element when billed because there is no interpretation and report included in the value assigned to the test code.

I hope that helps.
Cindy
Click to expand...
Cindy,

Would you count the influenza A and B test (87804, 87804-59) in the office as one or two tests ordered? Is there clarification on this because technically the 87804 represents one test.
 
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amwittler said:
Cindy,

Would you count the influenza A and B test (87804, 87804-59) in the office as one or two tests ordered? Is there clarification on this because technically the 87804 represents one test.
Click to expand...
Just seeing this after responding about billing fot the test. For E/M, I cannot definitively say it is wrong to count it but it feels much the same as a laboratory panel (1 panel = 1 test). I would count this as 1 test ordered and reviewed. Cindy
 
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