Wiki MDM for E/M Coding Tips Needed!

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aamedee92

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I'm working with the Interactive Score card on Novitas Solutions and just want to make sure I'm understanding the MDM section correctly.
Under MDM for the Amount and/or Complexity of Data Reviewed where it says "Review and/or order of tests in the medicine section of CPT (1 point)", does this refer to an injection given or a RX ordered?

Anyone have any examples or tips to make sure I get all the points correctly?

Thank you!
 
Looking at Novitas' interactive score sheet, I can see the ambiguity.
Let's look at what CMS guidelines state:

"The review of laboratory, radiology, and/or other diagnostic tests. A simple notation such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. Alternatively, document the review by initialing and dating the report that contains the test results."

I think the data collected or ordered for the section you are mentioning, would come from medical/other diagnostic tests. These tests would not fall under the umbrella of labs or radiology, but other tests can be performed still. Here are some of our examples:
  • EKGs
  • Cardiac cath
  • Echocardigram
  • Non-invasive vascular studies
  • Pulmonary function studies
  • etc.

If the prescriptions are pertinent to the treated problem(s), then they can be counted towards the Overall Risk (Management Options - Moderate). If appropriate and medically necessary, then injections can also be billed out.

Hope that helps!
 
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