Part B Insider - 2021 Issue 3
You Be the Coder: Count Tests This Way for Correct MDM Calculations
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Article Overview
This Q&A-style coding article discusses how to approach counting tests within the medical decision making data element for E/M services. It is aimed at coders and clinicians who need current guidance on test ordering, reviewing, and interpretation under CPT and AMA materials, with attention to how these issues affect moderate and high levels of data complexity.
Why This Topic Matters
Correctly counting test-related data is important for accurate E/M leveling and compliant documentation. The article addresses a commonly confusing area where guidance has not been fully clarified and highlights the need to track how tests are handled across encounters.
Article Sections
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Question
A reader raises a question about how test ordering and review were counted in a prior coding discussion and asks for clarification.
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Answer
The response discusses current CPT and AMA guidance at a high level and introduces practical considerations for counting tests in the MDM data element. It then presents several broad tips related to ordering, review, and interpretation.
What You Will Learn
- How test-related actions are discussed within the MDM data element
- Why test ordering and review can be confusing in E/M coding
- How current guidance and unresolved clarification issues affect coding practice
- How interpretation of tests by different providers fits into the broader data review discussion
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and other providers
- E/M documentation specialists
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