Code Labs and Tests Toward MDM With Confidence
Hint: You must meet two of the three elements to meet a specific level of MDM. Even the most seasoned coders often have trouble deciding with certainty what does and does not count toward medical decision making (MDM). Rae Jimenez, CPC, CDEO, CPB, CIC, CPMA, CPPM, CCS, president of Membership and Content at AAPC, sought to clear up this confusion at her session, “Decoding Diagnostics: How Labs and Tests Count Toward E/M Medical Decision Making,” during AAPC’s DOCUCON 2025 Conference. Continue reading for her expert tips and to review a few case examples to help you better understand how labs and tests are counted toward MDM. Observe CPT® Guidance on Tests for MDM Jimenez explained that when we decide the nature of a test, it is essentially determined by the CPT® code set. She further added that the previous guidelines stated that if a provider was receiving payment for a test, it couldn’t be included in the evaluation and management (E/M) level of service. Since then, the guidelines have been updated to read that if it’s a technical component-only test and there is no separately billed professional component to it, then it can be counted toward the MDM process. “That’s probably the biggest thing I want you to take away from this […] understanding the difference between when it’s technical only and when we’re performing the professional component of a test,” she said. Jimenez explained that when a provider orders a complete blood count (CBC) and reviews the results of the same CBC, it is only considered once toward MDM. Therefore, the test is only accounted for at the time it is ordered, as you cannot predict when the review of the test will take place. Remember that the intent of your provider ordering a test is they will eventually be reviewing the results. Because the review of the data could happen days later, it’s best to count it the day of the order, not later on. In the case of an abnormal result with additional or follow-up testing ordered later on, which would then be considered an order placed outside of the original date of service, that secondary testing could be counted separately because it is being ordered and reviewed outside of the original face-to-face encounter with the patient. “However, sometimes doing that additional work may not be worth the effort,” warned Jimenez. Remember you have to meet two of the three elements of MDM for it to count. To better understand the information discussed above, Jimenez shared this: Remember, if a professional component is billed on a service, you need to exclude that from MDM. If it’s being billed as a technical component only, you can include that as part of the MDM. Which Tests Typically Have a PC? Here are some tests that normally have a professional component: (Usually billed with modifier 26 [Professional component], unless billed as global): Here are some tests that do not have a professional component, as they are analyzed by machines and not manually interpreted: “A lot of people have a hard time keeping all of these straight and remembering what has a PC and what doesn’t,” said Jimenez. She included a path with some helpful documents from the Centers for Medicare & Medicaid Services (CMS) website to help readers: These documents will help you with further information about modifiers, surgical teams, and pre-/intra-/post-service coding. Multiplex Test Counting For multiplex test counting, “if it is one CPT® code, it is one test,” said Jimenez. “Even if test results end up generating analysis of multiple viruses, this would still be considered one test and can only be counted one time. One example would be, a [primary care provider] PCP orders a CBC glucose urinalysis, and they review it during the visit. It would not be billed separately, you would count it as three for the order, even though it’s being ordered and reviewed the same day since it’s the same provider. Three points would be given,” she said. Another example, “Say an [emergency department] ED physician orders a chest X-ray. The CPT® code here is 71045 [Radiologic examination, chest; single view]. They interpret it, and bill it with a 26 modifier. In this instance, it would not count toward the MDM because they are being paid separately for the professional component.” Examine These Case Examples Jimenez provided case examples for the audience to review together: Case No. 1 Patient is a 53-year-old presenting with a 3-day history of fever (102.4 ̊ F), chills, body aches, and persistent cough. Denies shortness of breath or chest pain. No travel history or known COVID-19 exposure. Objective vitals: Temp 102.4 ̊ F, HR 98, BP 132/78, RR 18, O2 sat 97% on room air General: Alert, in mild distress due to fever Lungs: Mild crackles at bases, no wheezes or rhonchi Heart: Regular rhythm, no murmurs Labs ordered: Assessment: Plan: Supportive care: fluids, acetaminophen, review labs in electronic health record (EHR) same day, no antibiotics at this time, return if symptoms worsen. The analysis from the audience: There were four unique tests that were ordered, and labs were reviewed during the encounter on the same day. Jimenez noted that it was interesting there were no chest X-rays performed to rule out pneumonia that day, but said, “It could have been that they were waiting to see what the labs showed before they ordered those. I would qualify this as ‘moderate’ in the data section and code this as a 99213 [Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.].” She pointed out that because of all the rule-outs and the viral symptoms, you would be coding the signs and symptoms on this visit from an ICD-10-CM perspective. She also mentioned it would be an opportunity to speak with the provider to give them pointers on how to improve their documentation skills going forward, as there were a few missing pieces of information that were not addressed in the notes but were mentioned in the assessment. Case No. 2 Subject is a 66-year-old presenting with 1-hour history of substernal chest pain radiating to left arm, associated with diaphoresis and nausea. Denies previous history of similar pain. No known coronary artery disease (CAD). Objective vitals: Temp: 98.6 ̊ F, HR 110, BP 142/86, RR 22, O2 96% on room air General: Anxious, mild distress Cardiac: Tachycardic, regular rhythm, no murmur Respiratory: Clear to auscultation bilaterally Tests ordered: EKG: Performed and interpreted by provider. Billed separately with 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) (interpretation only). Troponin sent to lab; results reviewed during the visit. Assessment: Plan: Send Troponin stat, consider transfer to ED based on labs and serial EKGs, discuss red flag symptoms and ED precautions. The analysis from the audience: Jimenez agreed with many audience members that this would be coded as a level 3 MDM due to the tests and having results of the tests, but the coders reading the notes don’t know what the results of those tests are, so they are unsure what the practitioner’s next step would be. “For the labs and tests ordered, it’s not just the action of ordering them, it’s what happens with the information. We really need to see what they are learning and how it is being included in their overall decision on what to do with the patient,” she said. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
