Part B Insider - 2021 Issue 3
You Be the Coder: Count Test Order and Review for MDM
Subscribe or sign in to view the full article.
Article Overview
This coding article addresses a common E/M documentation question for surgeons and other clinicians: how test ordering and later review affect medical decision making when reporting by MDM rather than time. It also discusses the related CPT guidance for office and outpatient E/M time-based reporting, including the broader categories of work that may count toward total time. The piece is useful for coders, auditors, and clinicians who need to understand how encounter-level data and time are treated differently under CPT E/M rules.
Why This Topic Matters
E/M leveling can change based on whether data review is counted under MDM or time. Understanding the distinction helps avoid inconsistent documentation and supports more accurate code selection.
What You Will Learn
- How CPT E/M medical decision making treats ordered test review as part of encounter data
- How encounter-based data review differs from time-based office and outpatient E/M reporting
- What broad types of work may be considered in total time calculations under CPT guidance
- How to think about test ordering and result review when reporting separately or non-separately
Who Should Read This
- Medical coders
- Billing staff
- Auditors
- Physicians
- Other qualified health care professionals
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com