How many points in MDM?

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Hi, gang. I'm trying to review since I haven't done E/M in a while and I keep finding contradicting information.

If it says "Lab ordered", it's 1 pt. How many for "Lab ordered & reviewed", though? Most says 2pt but some says 1.
Also, if they said "Labs performed. CXR was negative", how many points? 2? 3?

Thanks.
 
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csperoni

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The guidelines for outpatient E/M changed drastically in 2021. Outpatient and inpatient are coded very differently now. Which is this for?
 

csperoni

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For OP, follow the 2021 outpatient guidelines, which is based only on MDM (with new definitions) or total time. You count the test when ordered, and review is included. One of the significant changes is counting each unique test ordered. So if provider orders CXR, CBC w/ diff, BMP and UA, that is 4 unique test orders and would fall under moderate for amount/complexity of data. (Assumes provider did not perform the tests. If provider performs the test, you only count tests that do not have an interpretation component.)

In the ER or IP, you follow either 1995 or 1997 guidelines. You get 1 point for labs ordered regardless of how many (again, review included) and 1 point for radiology test ordered (review included), totaling 2 data points.

For OP, ER or IP, if you are not the clinician who ordered the test, you may then count the review.
 
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