Wiki Leveling of E/M

[njbrown]

Can you tell me if you can give a provider credit for leveling E/M for interpretation of audio done in office when it is in his note or does it specifically have to say that verbiage otherwise it would just be counted as review?

 

[csperoni]

By "audio done in office", I am assuming you mean some type of hearing test performed by your practice.
1) If the test has a professional component, you may count neither the order nor the interpretation in your E&M leveling. That work is paid for by billing the actual test itself.
2) If the test does NOT have a professional component and is a result only, you would count the order for E&M leveling and review is included. If the test were to be ordered not during an encounter, you could then count the review since you were not able to count the order.
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf Specifically:
The ordering and 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 the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended.