Wiki Counting labs ordered between visits?

[Chun303]

I work in a office where we do infusions. Providers will usually see a patient for an ov, and in this case no labs ordered with E&M. Patient will come in for infusion only but labs are drawn on a seperate day. The provider reviews them with patients next ov. My question is would we count the labs as we do when ordered. Ex CBC, CRP,ALT ,GFR would still equal moderate since they were not counted for in previous ov?( 4 unique tests) Or one review of data? There was no previous credit given for labs ordered. This is usually just a standard protocol for infusion pts for monitoring labs to check toxicity etc. Thanks in advance!

 

[EditaPetrosyan]

Based on AMA Code and Guideline - 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 other qualified health 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.

A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.