Wiki Counting the "ordering" of a test if you are separately billing for it

wright10

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I am seeing many differing opinions. Here is my general take away from the new 2021 guidelines: Per AMA and CPT "The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately." There is no mention of order. The provider still had to use their medical decision making to decide which test to order, regardless of if we are billing for it or not. They also state "When the physician or other QHCP is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report should not be counted in the medical decision making when selecting a level of office or other outpatient service." Again, this says nothing about him not being able to get credit for the ORDER. In addition, AMA/CPT says "Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not subsequent encounter." There is no mention as to if we are separately reporting it or not. To me, I am interpreting this to mean that if my provider orders and separately bills for a CBC and A1C on 01/01/21 I give him credit for ordering 2 labs. When he brings the patient back on 01/03/21 and goes over the results, I give 0 data points. Sometimes he may just have the nurse relay the results to the patient over the phone. In addition, if my provider orders a CT on 01/01/21 to be done at the hospital (not separately billed) and I give him credit for 1 ordering of a test. When he brings the patient back to review the radiologist report, that gets 0 data points. If my provider independently reviews the scan himself, I DO give credit for Category 2.
 
If the provider bills for a test, even if it will be on a future date, he doesn't get credit for the order in the MDM. This is because the decision-making for the order is included in the CPT charge. But I agree, the way the guidelines are worded doesn't make this clear.
An auditor sent this to me which has been helpful:
1) If a provider orders and interprets (and bills for) a diagnostic test or lab (e.g. visual field, A1C) on same day as visit – no credit in the MDM. This is correct. There would be no MDM credit for a test that was billed.
2) If a provider orders and interprets (and bills for) a diagnostic test or lab (e.g. visual field, A1C) on same day, and orders future diagnostic test or lab that he does not bill for – 1 credit for future order in MDM. This is correct. The order includes the review so there would be no separate MDM credit for the review.
3) If a provider orders a future diagnostic test (e.g. visual field) on the same day as a visit (only E/M billed), we get 1 credit in MDM for the order even though that same provider will interpret the visual field (and bill for the interp.) at a later date. No. This is not correct. The review and interpretation are included in the order. If the service is billed, even at a later date, it cannot be used for MDM level selection.
4) If a provider orders a diagnostic test or lab (does not bill for the interpretation) and reviews the results at a future visit-1 credit in MDM for ordering the test at the initial visit and 1 credit for review of the results at the future visit. No. This is not correct. The order includes the review. The provider receives one MDM credit for the order and the review even if the review is performed at a subsequent visit.
5) If a provider documents and reviews an old test (but previously billed for this test) – no credit in the MDM. This is correct.
6) If a provider documents and reviews an old test that was billed by someone else – 1 credit in MDM. The answer depends upon whether the test was ordered by a physician or QHP from the practice. As an example, if another physician in the practice ordered the test and billed for it, the review would not be part of MDM selection. If the test was ordered by a physician from a different practice, this would be an independent interpretation of the results and could be used for MDM level selection.
 
If the provider bills for a test, even if it will be on a future date, he doesn't get credit for the order in the MDM. This is because the decision-making for the order is included in the CPT charge. But I agree, the way the guidelines are worded doesn't make this clear.
An auditor sent this to me which has been helpful:
1) If a provider orders and interprets (and bills for) a diagnostic test or lab (e.g. visual field, A1C) on same day as visit – no credit in the MDM. This is correct. There would be no MDM credit for a test that was billed.
2) If a provider orders and interprets (and bills for) a diagnostic test or lab (e.g. visual field, A1C) on same day, and orders future diagnostic test or lab that he does not bill for – 1 credit for future order in MDM. This is correct. The order includes the review so there would be no separate MDM credit for the review.
3) If a provider orders a future diagnostic test (e.g. visual field) on the same day as a visit (only E/M billed), we get 1 credit in MDM for the order even though that same provider will interpret the visual field (and bill for the interp.) at a later date. No. This is not correct. The review and interpretation are included in the order. If the service is billed, even at a later date, it cannot be used for MDM level selection.
4) If a provider orders a diagnostic test or lab (does not bill for the interpretation) and reviews the results at a future visit-1 credit in MDM for ordering the test at the initial visit and 1 credit for review of the results at the future visit. No. This is not correct. The order includes the review. The provider receives one MDM credit for the order and the review even if the review is performed at a subsequent visit.
5) If a provider documents and reviews an old test (but previously billed for this test) – no credit in the MDM. This is correct.
6) If a provider documents and reviews an old test that was billed by someone else – 1 credit in MDM. The answer depends upon whether the test was ordered by a physician or QHP from the practice. As an example, if another physician in the practice ordered the test and billed for it, the review would not be part of MDM selection. If the test was ordered by a physician from a different practice, this would be an independent interpretation of the results and could be used for MDM level selection.
This is very helpful. What happens in a practice with multiple specialties? If a neurologist from the practice orders a test, let’s say an MRI and a radiologist in that practice reads the scan, and bills it can the neurologist get 1 point for ordering?
 
This is very helpful. What happens in a practice with multiple specialties? If a neurologist from the practice orders a test, let’s say an MRI and a radiologist in that practice reads the scan, and bills it can the neurologist get 1 point for ordering?
Yes, the neurologist would get credit for ordering the MRI since he's in a different specialty.
 
There was an update to the guidelines on 3/9/21 https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
So now there's this:
Question: If I order and bill for a quick strep test in my office, do I count the order, the review or both?

Update: 3/9/2021: You can credit the order. The AMA document with technical corrections now allows a group to credit the order of a test, even if billing for it.

Question: Do you have any clarification regarding lab tests that are ordered and run in-house? Can these be included as part of MDM.

Answer: Yes, the AMA’s 3/9/2021 document now allows Category 1 credit if you order the test and bill for it.

The document still says that you don’t double count the order and the review of the same test. If you order a CBC that is sent out, the order is considered part of the review. This is from the CPT Assistant, November 2020 in the FAQ section, page 5, published by the AMA.

It is assumed that the physician or other QHP would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test. Ordering and reviewing a test are considered a single component for MDM on the date of the encounter, even if ordering the test and subsequent review are performed on different days.

https://codingintel.com/changes-to-history-and-exam-element-requirements-for-em-services/
 
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