Medicare Compliance & Reimbursement - 2021 Issue 5
Reader Questions: Follow These Bullet Rules
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Article Overview
This article addresses a reader question about how test ordering and review are counted within medical decision making documentation. It also discusses broader CPT and AMA-related guidance on test-related data elements, interpretation, and how separately billed services can affect MDM data counting. The piece is aimed at coders and compliance staff who work with office/outpatient E/M documentation.
Why This Topic Matters
MDM data counting affects E/M level selection and documentation accuracy, so even small clarification points can change code assignment and audit risk. This article summarizes practical guidance on test-related bullets and related CPT/AMA considerations.
What You Will Learn
- How test ordering and review are discussed within MDM data counting
- How separately billed tests may affect the data element
- How interpretation of tests performed by another provider is addressed in MDM guidance
- What general CPT and AMA clarification issues are mentioned in relation to test-related bullets
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician documentation staff
- Billing personnel
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