Evaluation and Management Guidelines: Interpreting Tests/ Studies (October 1997)

Why This Topic Matters

Understanding how test interpretation and record review fit into E/M services helps avoid inappropriate separate reporting and supports more consistent documentation and coding practices.

Article Sections

1. Coding Communication

   Introductory communication from the publication introducing the topic and the context for the guidance that follows.

2. Evaluation and Management Guidelines: Interpreting Tests/ Studies

   Discussion of how E/M guidance addresses diagnostic test performance, interpretation, and separate reporting concepts.

3. E/M Guidelines: Time

   Overview of how record review, test review, and related non-face-to-face work are considered in the time component of E/M services.

4. E/M Guidelines: Medical Decision Making

   Summary of how the review and analysis of records and tests relates to medical decision making in E/M coding.

5. Using Code 76140

   Illustrative coding discussion focused on a radiology-related consultation service and how it is distinguished from routine review in an E/M encounter.