MDM data FAQs: Don’t double-count the order and review of a single test

The new rules for coding outpatient evaluation and management (E/M) office visits have drawn questions about what physicians can count toward the “data” portion of medical decision making (MDM). Here are some of those questions, and answers:

Q — If I order a test during one visit, and review the results during a subsequent visit, can I count it toward the MDM of both visits?

A — No. The CPT 2021 Professional Edition states on page 14 that "Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. "

This means that, per CPT rules as written, both the ordering and review of a particular test is considered one data unit. It is assumed that the ordering physician or qualified health care professional (QHP) would also provide review of the tests ordered. If a physician or QHP orders a test today and reviews it today, he or she could only count one data point for it. Similarly, a test ordered today but reviewed days later could not be claimed as a data element today and also at a follow-up visit next week, or next month.

The website Coding Intel addressed a question like this in a recent FAQ:

Question: If I order an MRI at a visit on Sept. 20, and review it with the patient at a follow up visit on Sept 27, do I count the order on the 20th and the review on the 27th? I didn’t bill for the MRI or the interpretation.

Answer: No, count it once, at the order.

Coding Intel’s author cited the previously mentioned CPT guidance, as well as a November 2020 passage from the American Medical Association’s (AMA) CPT Assistant newsletter that reads, “It is assumed that the physician or other QHP would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test.”

Q — If another member of my practice orders labs, but then I review them during a subsequent visit, can I count it towards my MDM?

A — Not if your colleague who ordered the labs is of the same specialty as you. You may only count review of data separately if the tests were ordered by an external physician (e.g., an Emergency Department physician orders a chest x-ray and labs that are then reviewed by a family physician during a follow-up visit).

Q — If the lab is performed "in-house," how do I count the data points?

A — Under the current guidelines, if billing for the lab within your facility, do NOT include that order or review as Category 1 data. A question like this was also addressed on the Coding Intel page, which states that, “the AMA has confirmed that if you bill for the lab test, you don’t count it as ordered or reviewed.”

These rules are built around the principle that practices should treat the ordering and reviewing of a single test as a single unit of data for MDM purposes, even if the ordering and reviewing happen on different days, or are done by different physicians (of the same specialty) within that practice.  

While that principle may not fit neatly in the workflow of a primary care practice, it’s important to be aware that that’s how MDM data is treated. It could prevent you from being accused of upcoding for counting the same test twice (once when ordered and once when reviewed).

— Samuel L. Church, MD, MPH, CPC, CRC, FAAFP

Northeast Georgia Medical Center Family Medicine Residency, Core Faculty

AAFP Advisor, AMA CPT Editorial Panel