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

Why This Topic Matters

Understanding how data from ordered tests is counted under CPT E/M guidance helps avoid inconsistent interpretation of medical decision making and supports accurate E/M level selection. It also helps distinguish MDM-based reporting from time-based reporting, which follows different counting principles.

Article Sections

1. Question

   Presents a scenario about whether test results received on different dates can be considered in the data component of E/M medical decision making.

2. Answer

   Explains the general CPT E/M approach to counting ordered test review within medical decision making and notes the relationship to separately reported services.

3. CPT® guidance on data reviewed and analyzed

   Summarizes CPT guidance describing the data component of E/M medical decision making and how test ordering and review are treated within that framework.

4. Caution: time-based office/outpatient E/M reporting

   Contrasts the MDM approach with time-based office and outpatient E/M reporting and notes that time calculations follow a different CPT framework.