Outpatient Facility Coding Alert - 2021 Issue 9
Reader Questions: Use One Bullet for Test Order and Review
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Article Overview
This reader Q&A explains a recent office/outpatient E/M coding question about medical decision making and the data component tied to tests. It focuses on how the guidance is applied in practice, when test activity is counted, and where related CPT-based distinctions may affect reporting. The article is aimed at coders and billing staff working with office/outpatient E/M services and broader test-related documentation issues.
Why This Topic Matters
Accurate MDM data counting can affect E/M level selection and compliance. The article helps readers understand the general framework for test-related data reporting under the office/outpatient E/M rules and recognize when related CPT considerations may come into play.
Article Sections
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Question
The reader raises a question about office/outpatient E/M medical decision making and test-related data counting.
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Answer
The response discusses the general CPT and AMA context for ordering, reviewing, and interpreting tests, along with broad guidance on how the issue is approached.
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The most up-to-date advice on MDM bullet counting can be summarized in these three tips:
This section presents a set of practical points summarizing current office/outpatient E/M MDM data-element guidance and related CPT considerations.
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Remember:
The closing note limits the guidance to specific office/outpatient E/M code ranges and distinguishes them from other E/M code families.
What You Will Learn
- How the article frames test-related data counting in office/outpatient E/M medical decision making
- What broad categories of test activity are discussed in relation to MDM data elements
- How the article distinguishes office/outpatient E/M services from other E/M settings
- Why CPT-related interpretation and reporting issues matter to MDM documentation
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Compliance professionals
- Practice managers
- Physician documentation teams
Codes Discussed
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