I am not aware of any official guidance on this specific situation, so I would love some debate and opinion from others. This is regarding amount/complexity of data for 2021 outpatient.
Visit 1: Provider orders PET CT. We count the 1 point for the PET CT when ordered.
A few days later, insurance denies the PET CT, but will approve CT abdomen/pelvis and CT chest, which is ordered, but not as part of a visit.
Visit 2: Patient returns to review results of the CT abdomen/pelvis and CT chest (2 tests).
I feel there are 3 options here:
1) Don't count the review at all, since you counted ordering the test, even though the test changed and an additional test.
2) Count the review as 2 tests since you never counted ordering of the CTs.
3) Count the review as only 1 test since you already received credit for ordering/reviewing 1 test and wound up doing 2.
I am leaning toward option 2 - counting review of 2 tests since there was additional medical decision making in ordering different testing and were not counted previously. But it kind of feels like a loophole since you already counted 1 order/review for the PET CT that wasn't reviewed, so I'm considering option 3.
Rationale from AMA guidelines with my emphasis added:
Analyzed: The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter. 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.
Thoughts???
Visit 1: Provider orders PET CT. We count the 1 point for the PET CT when ordered.
A few days later, insurance denies the PET CT, but will approve CT abdomen/pelvis and CT chest, which is ordered, but not as part of a visit.
Visit 2: Patient returns to review results of the CT abdomen/pelvis and CT chest (2 tests).
I feel there are 3 options here:
1) Don't count the review at all, since you counted ordering the test, even though the test changed and an additional test.
2) Count the review as 2 tests since you never counted ordering of the CTs.
3) Count the review as only 1 test since you already received credit for ordering/reviewing 1 test and wound up doing 2.
I am leaning toward option 2 - counting review of 2 tests since there was additional medical decision making in ordering different testing and were not counted previously. But it kind of feels like a loophole since you already counted 1 order/review for the PET CT that wasn't reviewed, so I'm considering option 3.
Rationale from AMA guidelines with my emphasis added:
Analyzed: The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter. 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.
Thoughts???
