Question 2021 Determining MDM for exam with procedures

LauraB

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Hi, I code for Dermatology clinic visits & have a 2021 E&M question. I know the data part of MDM talks about labs and tests not being counted towards the MDM level if you are billing for them. But how does that compare for encounters where you are billing an exam and procedure(s)?

For a generic example, pt comes in for a skin check and they also have a bump bothering them on the left hand. The doctor finds several minor issues during the skin check, decides to shave off the hand bump as treatment & also biopsy a suspicious spot on the back.

Since you are separately billing a CPT for the 11305 and 11102, can you count those when figuring your MDM - towards either your Data or Risk elements? I’ve tried researching for this and any actual examples, but all I seem to find is info on tests & labs and not actual Procedures. Any information is greatly appreciated!! Thank you in advance!
Laura
 
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