2021 E/M Changes: Are You Coding Unique Tests Properly?
Review the AMA’s updated definition of what constitutes a unique test.
Many coders are asking the question, “What is a unique test?” As always, we must first turn to the guidelines to see how “test” is defined. In the original published guidelines, the American Medical Association (AMA) stated:
“Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg basic metabolic panel ) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.”
The AMA made technical corrections to the 2021 Evaluation and Management (E/M) Guidelines for Office and Other Outpatient and Prolonged Services and posted them on March 9, 2021. In the technical corrections, the AMA modified the above definition of “test,” removing the word “unique” and adding the following sentence: “For the purposes of data reviewed and analyzed, pulse oximetry is not a test.” The technical corrections further clarified this point by adding “unique” to its list of definitions for the elements of medical decision making (MDM):
“A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.”
Break Down the Guidelines
A unique test is defined by CPT® code, not the number of tests performed. If the provider orders a panel test that contains tests with individual CPT® codes, all of those individual CPT® codes are bundled into the CPT® code for the panel test and counted as one unique test.
For example: The provider orders 80051 Electrolyte panel. Although this panel includes four tests — 82374 Carbon dioxide (bicarbonate), 82435 Chloride, 84132 Potassium, and 84295 Sodium — this is considered and counted as one unique test, not four, and reported with 80051 only.
The AMA also states that serial tests — multiple results of the same unique test — with comparison count as one unique test, even though multiple results are reviewed.
For example: The provider orders serial glucose testing over several hours or days and compares the results during an E/M service. Although the same test is repeated multiple times, the technical corrections state that serial tests count as one unique test.
Lastly, the AMA gives an example to explain how tests that have overlapping elements are not unique, even if they are identified with two distinct CPT® codes: A complete blood count (CBC) with differential and a CBC without differential would constitute one unique test.
For example, CPT® code 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count and CPT® code 85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) are considered one unique test because they have overlapping components.
During the creation process of the changes, the AMA says they were not trying to incentivize the provider, but rather give credit to the provider for the work performed during the encounter. If a provider is going to bill for the professional component of a test, credit cannot be given for the ordering or reviewing of the test because they are already being paid for the test. Providers will not get credit for generating business for themselves.
During a webinar released by the AMA last year, it was stated that the review of a unique test is inherent in the ordering of the unique test. Therefore, if the provider orders a test, the provider will not also get credit for the review of the test, even if the review is performed at a subsequent encounter.
Remember that the AMA makes technical corrections to CPT® throughout the year. These corrections are not printed in your CPT® code book. You will need to refer to the errata and technical correction to apply the guidelines appropriately and code correctly. You can find the technical corrections made to the E/M guidelines on AMA’s website.