decisionhealth Newsletters, Part B News - 2021 Issue 2 (February)
For E/M visits, review 6 questions and answers to clarify the new data review rules
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Article Overview
This premium article addresses practical questions raised during a CPT and RBRVS symposium about the 2021 office/outpatient E/M rules. It is aimed at coders, billers, and practice staff who need a clearer understanding of how test ordering, result review, interprovider discussion, and related data-review activities fit into time and medical decision-making for office visits. The discussion focuses on general guidance for avoiding double counting and understanding when related work is considered part of an encounter.
Why This Topic Matters
E/M leveling depends on accurate interpretation of time and medical decision-making elements, and test-related work can easily be counted incorrectly. This guidance helps practices reduce coding errors and better align documentation with current office visit rules.
Article Sections
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2021 E/M office visits
An overview of the topic and the context for the data-review questions discussed in the article.
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Tests and follow-up visits
Questions and answers about how test results and related follow-up work fit into office visit coding considerations.
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Order, review or both?
Discussion of whether ordering and reviewing test results can be counted separately across encounters and follow-up visits.
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In-house tests
Guidance on situations involving tests performed within a practice and how those scenarios affect reporting considerations.
What You Will Learn
- How the article frames test-related work under the 2021 office/outpatient E/M structure
- What types of questions practices are asking about data review and follow-up encounters
- How the article addresses concerns about test ordering, result review, and related documentation
- Why in-house testing scenarios raise special coding and billing considerations
Who Should Read This
- Medical coders
- Medical billers
- Physician practices
- Compliance staff
- Revenue cycle staff
- Clinical documentation staff
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