When Does Test Interpretation Factor into E/M Code Selection?

When Does Test Interpretation Factor into E/M Code Selection?

Whether you may assign credit in the data review section of medical decision-making (MDM) if the provider separately bills for the professional component of a test is a matter of payer interpretation and policy, as explained by the American College of Emergency Physicians (ACEP):

If I bill for an ECG or X-ray interpretation, can I also count this service (assign a point) in the Evaluation and Management Medical Decision-Making (MDM) value as listed on the MDM table in the CMS distributed Marshfield Clinic tool for review of images/tracings?

On a basic level, there is the potential for 3 “points” in the CMS-suggested Medical Decision Making (MDM) audit scoring in the area of Amount And/ Or Complexity of Data to Be Reviewed for radiology/cardiology/lab and other diagnostic services. One point is assigned for ordering the study and using the results for patient evaluation/management. Two points are available for the direct visualization of the tracing/film/specimen.

It is possible to give credit for the single point assigned for ordering of the study in addition to billing for the interpretation of the test. It is the latter 2 points that raise some question and are discussed in this scenario. This scoring system is derived from a CMS-suggested audit scoring sheet widely distribute nationwide.

The discussion revolves around the fine point of whether the complexity of data to be reviewed is an assessment of service separate from the work of the interpretation of the test. If these are separate, then the 2 points can be given in addition to billing for the interpretation of the test. CPT addresses this issue by noting that the interpretation of diagnostic tests is not included in the levels of E&M services. On the other hand, Medicare seems to differentiate between a “report” and a “review” in respect of billing and getting credit under the complexity of data section of the MDM. In that there is no specific clarification on this issue and payment policies do differ, you are advised to contact your local carrier for advice.

Payers Set the Rules

Be sure to know your individual payers’ rules before taking credit for independent visualization of at test in the Amount and/or Complexity of Data Reviewed Section of MDM if the provider is billing separately for the test interpretation.

Evaluation and Management – CEMC

For example, Novitas Solutions clarifies that you should not assign credit in the data review section of medical decision-making (MDM) if the provider is separately billing the professional component of a test:

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If the provider is billing separately for the interpretation of a test in the radiology and/or medicine section of the CPT, then that same physician should not take credit for the independent visualization of that test in the Amount and/or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M….If the provider is not billing separately for the interpretation of the test or the test was performed by another provider and that physician is independently visualizing the test, then the provider may take credit for the independent visualization of that test in the Amount and /or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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