tci General Surgery Coding Alert - 2021 Issue Q1

You Be the Coder: Count Test Order and Review for MDM

Question: If the surgeon bills an E/M visit based on medical decision making (MDM), not time, can they consider test results received on different dates of service toward the complexity or amount of data reviewed and analyzed that counts as an element of MDM? Missouri Subscriber Answer: Yes, you can count the test result review as part of the MDM for the E/M service as long as you’re not reporting the test review separately. You should count the test order and review as data for the encounter in which the test was ordered, even though it may not...

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