2021 E/M guidelines: Is it an independent interpretation or review of test results? Here’s how to tell

Why This Topic Matters

Understanding this guidance affects how office visit MDM is supported in the record and how providers and coders interpret diagnostic test-related data elements. It helps reduce confusion around documentation practices for encounters that involve ordered tests and subsequent review or interpretation.

Article Sections

1. When the doc ordered the test

   This section introduces the central question about whether ordering a test affects how interpretation is treated in the E/M framework. It also references guidance discussed by AMA officials.

2. Must have separate tech, pro reports

   This section discusses the types of diagnostic tests and reporting structures involved in the guidance. It focuses on the distinction between different forms of test review within the office visit E/M context.

3. Doc should note own impression

   This section addresses the documentation expectations associated with the topic. It emphasizes the kind of narrative support that may be needed in the note.