decisionhealth Newsletters, Coder Pink Sheets - 2025 Issue 5 (May)
Q&A: The doc’s practice did the imaging test. Can we still count it toward MDM?
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Article Overview
This article addresses a coding question about whether diagnostic imaging ordered by a physician can be counted in E/M medical decision-making when the same practice performs and bills for the study. It is written for medical coders, billers, and clinicians working with E/M documentation and diagnostic test reporting, and it discusses the general framework for distinguishing imaging studies from other tests in MDM calculations. The piece focuses on practical interpretation of AMA guidance and how separate professional interpretation affects what can be counted.
Why This Topic Matters
Correct MDM reporting affects E/M level selection and helps avoid counting work that is already captured elsewhere in billing. The topic is especially relevant when a practice both orders and performs diagnostic imaging or other tests.
What You Will Learn
- How diagnostic imaging relates to E/M medical decision-making
- Why separate billing for professional interpretation matters
- How same-day versus later testing affects MDM considerations
- How the guidance differs for imaging versus tests without separate interpretation
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Advanced practice providers
- Compliance professionals
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