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E&M - Data - Order Cardiology tests

J

JDACPC

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Local Chapter Officer
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171
Location
Richfield, PA
Pt is seen in Cardiology office with order for follow up/future testing, say EKG or echo. While it's likely pt may have the testing done by this office and we would bill it out professionally (so can't count the order), pt may go across town and get it done. Do you count the order 100% of the time? If pt is supposed to have it done 6 months or a year from now, how are we to know where pt will have it done and if we can count it? I need authoritative guidance on this if anyone has it. Thank you!
 
Hi, hope this helps:
  • Do you count the order 100% of the time? - yes, if it significantly changes the MDM level.
  • If pt is supposed to have it done 6 months or a year from now, how are we to know where pt will have it done and if we can count it? - Yes, the order itself is counted in the encounter in which it is made and it doesn't depend on when/whether the patient completes the test. AAPC Ref: " The process of using data as one of the three elements of MDM. Ordered Tests that are presumed to be reviewed and analyzed when the results are reported are counted towards MDM in that encounter they are ordered. Tests that are ordered outside of an encounter(eg, future, recurring orders) may be counted in the encounter in which they are analyzed". (https://assets.ctfassets.net/i7kmp6...1677fa036772d4a910/AAPC_2024_EM_Worksheet.pdf)
 
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