When and how to count data under the revised E/M office guidelines

When the new rules for evaluation and management (E/M) office visits (CPT codes 99202-99215) went into effect at the beginning of the year, they immediately caused confusion about how to count “data” to determine the level of medical decision making (MDM). The CPT Editorial Panel recently made some revisions, retroactive to Jan. 1, that are intended to clarify the guidelines.¹

But family physicians may still have some confusion about counting data, specifically the category labeled “Tests and Documents.” Even with the revisions, the guidelines don’t always mesh well with their workflow, specifically when it comes to placing orders in preparation for future disease surveillance.

The recent revisions state:

Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed.

The workflow of many offices is to place orders for chronic disease monitoring (A1Cs, lipids, etc.) in the current visit note, to be performed prior to the next scheduled appointment. This creates a problem under the new guidance, because there won’t be any results from those orders reported until the follow-up appointment.

Electronic health records may capture this as a data element for the first visit, because the order is in that visit’s note. However, the future orders are often placed in the current treatment plan only for administrative purposes. These tests are actually, in essence, “ordered outside of an encounter” because they are not intended to be completed or analyzed as part of the current visit, much like a recurring lab item. Therefore, based on the revised guidelines, one would not count the lab order as a data element for the first encounter, but would instead count the interpretation of the results for the later encounter.

Regardless of when the lab/test component is captured, you may count either the “ordering” or the “review/analysis” of a particular lab/test, but not both. Don’t double-count the order and review of a single test.

The revised guidance also clarifies that labs and tests are only some of the eligible items under the “tests and documents” data category:

Combination of Data Elements: A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.

1. CPT Evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guidelines changes. American Medical Association. March 9, 2021. Accessed March 17, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

— Samuel Le Church, MD, MPH, CPC, FAAFP, AAFP CPT Advisor, and Emily Hill, PA, AAFP CPT Staff Advisor