2021 E/M coding office visit "unique test" question

[AnneWagner]

If we order an injection, that will be scheduled on a different date, but will be done in our clinic (so we will bill for it in the future), would this count as "Ordering of each unique test", in the complexity of data category 1?

 

[kimberlywatson]

An injection is not a test nor is it data to be reviewed, so this would never be counted in the Data to Review section.

 

[AnneWagner]

According to training I received, ordering X-ray's, ordering injections, ordering labs, ordering PT are all considered data points.

 

[kimberlywatson]

According to training I received, ordering X-ray's, ordering injections, ordering labs, ordering PT are all considered data points.

Injections and PT are types of treatment and would be considered as part of the Risk Section. Can you cite what training you are referring to?

 

[AnneWagner]

 

[kimberlywatson]

Hmm - still not following. Can you explain where you are seeing that injections and PT count as data? Keep in mind that the AMA defines tests as "laboratory services, diagnostic imaging, psychometric, or physiological data". The Data to Review section is all about what the provider uses to either initially diagnosis the patient or make determinations for further treatment. Once that is determined, treatments such as injections, PT, surgery, medication, etc. are prescribed which are part of the Risk.