CPT Knowledgebase - Apr 5, 2021

In the E/M Guidelines of the CPT 2021 code set, a sentence regarding the amount and/or complexity of data to be reviewed and analyzed states that [o]rdering 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. Does this mean that if a test is ordered and the results reviewed during the same office visit that two of the three requirements for Category 1 (Tests and documents) for amount and/or complexity of data to be reviewed and analyzed would be fulfilled? For example, if a clinician orders a urinalysis and then reviews the results of the test during the same office visit, would it be considered as having met the requirements to report limited level of Category 1 for amount and/or complexity of data to be reviewed and analyzed?

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