General Surgery Coding Alert - 2020 Issue 12
Reader Questions: Test Your MDM Knowledge Before Calculating Level
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Article Overview
This article addresses a reader question about the 2021 office and outpatient E/M medical decision making framework, with emphasis on how test ordering and later review are treated in the data component of MDM. It is aimed at coders, billers, and clinicians who document or select office and outpatient E/M levels and want a clearer understanding of CPT guidance related to test-related data credit.
Why This Topic Matters
Correctly understanding what counts in the MDM data element affects E/M level selection and compliance. The article helps readers distinguish between general test ordering, review of results, and services that already include interpretation or reporting.
What You Will Learn
- How the 2021 office and outpatient E/M MDM data element relates to test ordering
- How test review is treated when interpretation or reporting is already included in another service
- How bundled panels and separately reported tests are generally discussed in the context of MDM data credit
- How CPT guidance is applied to common office and outpatient documentation questions
Who Should Read This
- Medical coders
- Billing staff
- Physicians and other qualified health care professionals
- Compliance staff
Codes Discussed
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