Medicare Compliance & Reimbursement - 2020 Issue 12
Reader Questions: Test Your MDM Knowledge Before Calculating Level
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Article Overview
This reader Q&A addresses how the 2021 office and outpatient E/M medical decision making guidelines treat test ordering and review in the data category. It is aimed at clinicians, coders, and documentation staff who work with E/M leveling and want to understand the general framework for counting tests, bundled services, and related CPT guidance.
Why This Topic Matters
Accurate MDM support affects office and outpatient E/M leveling and documentation integrity. The article helps readers recognize when test-related activity may contribute to data review and when it is already part of another reported service.
Article Sections
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Question
A reader asks about applying the 2021 office and outpatient E/M medical decision making framework to test ordering and later test review. The question centers on how these activities relate to the data portion of MDM.
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Answer
The response discusses the general treatment of test ordering and review under CPT guidance for office and outpatient E/M services. It also addresses how bundled testing services are considered in the broader documentation framework.
What You Will Learn
- How the 2021 office and outpatient E/M guidelines address test-related data in MDM
- How bundled testing services are considered in the context of test counting
- How CPT guidance relates to reporting separate services that include interpretation or reporting
- What types of test activity may be relevant to the data element of MDM
Who Should Read This
- Physicians
- Qualified health care professionals
- Medical coders
- Clinical documentation staff
- Revenue cycle professionals
Codes Discussed
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