Wiki Counting Multiple Labs for Purposes of Data Reviewed Under 2023 Guidelines

[bsteinagel]

Greetings All,

I would like to clarify whether each lab represented by it's own cpt code counts as one point towards data reviewed for MDM under the new leveling guidelines. Example: provider orders 80061, 80053 and 82306. My understanding is that because these are three separate non-overlapping tests reported by their own unique cpt codes this would count as three points for data reviewed under 2023 guidelines. I am asking because our auditor that is saying labs only count as one point no matter how many labs were ordered--essentially she is grouping them all together and only giving one point. I thought this was the case under the old 95/97 guidelines but that this had changed with the 21/23 guidelines and we can now count these distinct tests individually.

The 21/23 CPT guidelines state quite clearly that "each unique test...is counted to meet a threshold number." I interpret this to mean that one point is given for each distinct cpt code as long as they don't overlap. Am I misunderstanding the guidelines? Thanks in advance for any advice. I know this has been discussed multiple times before but our auditor told us this today and I wanted to make sure I wasn't misinterpreting what the guidelines are saying. Many thanks for taking the time to answer.

 

[csperoni]

You are interpreting the guideline correctly. The auditor is wrong unless it's outpatient prior to 2021 or inpatient prior to 2023.
I will note you count them during the ordering and review is included.

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

States "Ordering of each unique test"
Unique: 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 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.

 

[Queizati]

Since you specifically asked about tests reviewed counted towards data and your auditor is telling you it only counts as one, is this a case of your physician reviewing lab results ordered from another provider (i.e a patient presents to their PCP after a visit with their cardiologist and the PCP reviews the results of all the labs ordered for that visit)?

If so, I believe all test results reviewed from that visit count toward one data point.

As csperoni mentioned from the E/M guidelines:
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.

 

[bsteinagel]

Thank you both for the responses. That was my understanding as well--that each unique test is given one point in the MDM. Just to clarify one additional thing: if a provider orders a test and reviews it at a followup visit they do not get credit for reviewing that test at the followup visit since the review is included--it is assumed the provider will review the results of any test ordered, correct? I have not been giving credit for review of test results at followup visits unless the documentation is clear that the test reviewed was from a provider of a different specialty or a provider from a completely different practice. Typically I only give credit for test review at new patient visits where the provider is reviewing outside records from a different physician. Is my approach correct?

Regards and thank you again for the advice.
Brad

 

[csperoni]

Thank you both for the responses. That was my understanding as well--that each unique test is given one point in the MDM. Just to clarify one additional thing: if a provider orders a test and reviews it at a followup visit they do not get credit for reviewing that test at the followup visit since the review is included--it is assumed the provider will review the results of any test ordered, correct? I have not been giving credit for review of test results at followup visits unless the documentation is clear that the test reviewed was from a provider of a different specialty or a provider from a completely different practice. Typically I only give credit for test review at new patient visits where the provider is reviewing outside records from a different physician. Is my approach correct?

Regards and thank you again for the advice.
Brad

Yes, exactly correct. Generally you count the order and review is included. You count review only if ordered between E&M visits or ordered by a clinician in a different practice or a different specialty. And then review of all materials from that other clinician counts as one.

 

[MelodyCPC]

Since you specifically asked about tests reviewed counted towards data and your auditor is telling you it only counts as one, is this a case of your physician reviewing lab results ordered from another provider (i.e a patient presents to their PCP after a visit with their cardiologist and the PCP reviews the results of all the labs ordered for that visit)?

If so, I believe all test results reviewed from that visit count toward one data point.

As csperoni mentioned from the E/M guidelines:
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.

I just posted a question related to this same topic (sorry, I should have read this thread first!). My interpretation of all of the published Q&A from CMS and AMA is aligned with your response, but some others in my organization are having difficulty agreeing that they can't count per CPT for these. When these are copied/pasted into the progress note, it doesn't reflect who the ordering provider was on the lab test, so there is a bit of additional "digging" that the coder must do to understand how that data element should be counted in Category 1.

 

[MelodyCPC]

Thank you both for the responses. That was my understanding as well--that each unique test is given one point in the MDM. Just to clarify one additional thing: if a provider orders a test and reviews it at a followup visit they do not get credit for reviewing that test at the followup visit since the review is included--it is assumed the provider will review the results of any test ordered, correct? I have not been giving credit for review of test results at followup visits unless the documentation is clear that the test reviewed was from a provider of a different specialty or a provider from a completely different practice. Typically I only give credit for test review at new patient visits where the provider is reviewing outside records from a different physician. Is my approach correct?

Regards and thank you again for the advice.
Brad

I agree with your approach.

Depending on your specialty and visit frequency for your patients, there are more scenarios to watch for - such as when a lab/imaging study was ordered outside of a face-to-face visit and then the patient comes in for an E/M and the results are analyzed. Typically, I find a telephone entry in the chart that explains how/why the order was entered and confirms it wasn't already counted in a previous face to face encounter.

I've also been monitoring for scenarios where the lab testing is a "standing" order for which the subsequent test result can be counted at the next encounter when it is reviewed/analyzed. I don't think it can always be presumed that the order/review was already counted at a prior E/M, but these are harder to identify because the plan of care may not be specific in terms of how often the labs will be ordered and is more of a visit-by-visit decision depending on the status of their chronic condition.

These discussions are very helpful!

 

[bsteinagel]

Thank you all for the info. Yes, there are the other scenarios to watch for like you said. Typically when a lab is ordered outside of an e/m visit I count the review at the visit when the results are reviewed. I do have some providers that always document test and outside record review at every visit. They think they can get credit for this every time but I think the guidelines are clear they can only get credit for this once--they can't continue to review the same results/records and get credit for those at every visit. Good info! Thanks!

 

[flowergrl]

So another question. If we have a provider that orders multiple lab dates at once (such as monitoring labs for a chronic condition quarterly), when do we count the labs? If the provider see's the patient on 1/5/23 and orders labs for 4/5/23, 7/5/23, 10/5/23... and I credit the ordering of the labs on 1/5/23, the provider won't get credit at any of the future dates for data. What if their office visit on those future dates depend on that data to support their level 4 MDM coding? We're basically giving the provider credit for data on one date when they could be getting credit on 3 dates instead (for the reviews).

But if we make that agreement with the provider, that we only count the reviews, what if they do a telephone call on one of those later dates prior to that visit (or it gets rescheduled), instead of going over the results with the patient face to face? Do they then not get any credit for those labs at all? Because we skipped giving credit for the ordering on 1/5/23, but then went over the results on the phone. This is the problem we're having.

 

[csperoni]

So another question. If we have a provider that orders multiple lab dates at once (such as monitoring labs for a chronic condition quarterly), when do we count the labs? If the provider see's the patient on 1/5/23 and orders labs for 4/5/23, 7/5/23, 10/5/23... and I credit the ordering of the labs on 1/5/23, the provider won't get credit at any of the future dates for data. What if their office visit on those future dates depend on that data to support their level 4 MDM coding? We're basically giving the provider credit for data on one date when they could be getting credit on 3 dates instead (for the reviews).

But if we make that agreement with the provider, that we only count the reviews, what if they do a telephone call on one of those later dates prior to that visit (or it gets rescheduled), instead of going over the results with the patient face to face? Do they then not get any credit for those labs at all? Because we skipped giving credit for the ordering on 1/5/23, but then went over the results on the phone. This is the problem we're having.

The AMA guide is the best reference and answers this:
Analyzed: The process of using the data as part of the MDM. The data element itself may not be
subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis,
evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are
reported. Therefore, when they are ordered during an encounter, they are counted in that
encounter. Tests that are ordered outside of an encounter may be counted in the encounter in
which they are analyzed. In the case of a recurring order, each new result may be counted in the
encounter in which it is analyzed. For example, an encounter that includes an order for monthly
prothrombin times would count for one prothrombin time ordered and reviewed. Additional
future results, if analyzed in a subsequent encounter, may be counted as a single test in that
subsequent encounter. Any service for which the professional component is separately reported
by the physician or other qualified health care professional reporting the E/M services is not
counted as a data element ordered, reviewed, analyzed, or independently interpreted for the
purposes of determining the level of MDM.

 

[isleflow0r]

If diagnostics are ordered/analyzed in a previous encounter, my providers are inquiring if it can be counted towards time in a subsequent encounter as the specialty normally always looks as previous imaging which plays a role with determining patient's next steps in A/P?

I do not think it can be counted as it seems that leaves room for abuse on utilizing time and time may come into play for being documented for every encounter but at the same time providers are instructed to use what is more "beneficial" when it comes to LOS selection and review of records are incorporated when time is used. Is there a guide on this?

 

[medicalauditor]

If diagnostics are ordered/analyzed in a previous encounter, my providers are inquiring if it can be counted towards time in a subsequent encounter as the specialty normally always looks as previous imaging which plays a role with determining patient's next steps in A/P?

I do not think it can be counted as it seems that leaves room for abuse on utilizing time and time may come into play for being documented for every encounter but at the same time providers are instructed to use what is more "beneficial" when it comes to LOS selection and review of records are incorporated when time is used. Is there a guide on this?

If diagnostics are ordered/analyzed in a previous encounter, my providers are inquiring if it can be counted towards time in a subsequent encounter as the specialty normally always looks as previous imaging which plays a role with determining patient's next steps in A/P?

I do not think it can be counted as it seems that leaves room for abuse on utilizing time and time may come into play for being documented for every encounter but at the same time providers are instructed to use what is more "beneficial" when it comes to LOS selection and review of records are incorporated when time is used. Is there a guide on this?

Yes, if the tests were ordered in a previous encounter, then the time the provider spends to review the tests would count towards time for E/M. Here are the AMA guidelines:
"For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). It does not include any time spent in the performance of other separately reported service(s)." The guidelines go on to provide a list of activities that would count towards time:
"Physician or other qualified health care professional time includes the following activities, when performed:■ preparing to see the patient (eg, review of tests)■ obtaining and/or reviewing separately obtained history■ performing a medically appropriate examination and/or evaluation■ counseling and educating the patient/family/caregiver■ ordering medications, tests, or procedures■ referring and communicating with other health care professionals (when not separately reported)■ documenting clinical information in the electronic or other health record■ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver■ care coordination (not separately reported)"