Wiki Unique test ordered for MDM

[georsms]

I understand the definition of a unique test and how it relates to E/M MDM. My question is regarding procedures that are more invasive than simple X-rays, EKGs, MRIs, etc. Hypothetically speaking, and please forgive me if this is not a situation that occurs in a clinical setting as I have just been recently certified if a physician wants an angiogram, biopsy of some kind, or a procedure that involves some level of invasiveness can they order it and then another physician performs it? If so would that count as a unique test ordered since it is used to measure physiological data through labwork or imaging? Any help would be greatly appreciated.

 

[luvbuix]

or could some of these fit into the minor procedures (hopefully with risks/benes) category under risk?

 

[MelodyCPC]

I understand the definition of a unique test and how it relates to E/M MDM. My question is regarding procedures that are more invasive than simple X-rays, EKGs, MRIs, etc. Hypothetically speaking, and please forgive me if this is not a situation that occurs in a clinical setting as I have just been recently certified if a physician wants an angiogram, biopsy of some kind, or a procedure that involves some level of invasiveness can they order it and then another physician performs it? If so would that count as a unique test ordered since it is used to measure physiological data through labwork or imaging? Any help would be greatly appreciated.

I am currently researching the same issue....if a CT Angiogram of pelvis and lower extremities is ordered, can this be scored as a minor procedure under the patient management element of MDM? or is it only scored under work performed/data analyzed element?

 

[georsms]

I am currently researching the same issue....if a CT Angiogram of pelvis and lower extremities is ordered, can this be scored as a minor procedure under the patient management element of MDM? or is it only scored under work performed/data analyzed element?

If there is an actual order for these procedures and the physician did not interpret anything, then it should count as a data point, and if the physician assessed the possible risks involved then that should count towards the risk group as well, that is how I understand it at least. For radiologists, the E/M is inherent within the encounter and not reported separately, unless he/she needs to perform a separate e/m that is different from the reason for the encounter.

 

[georsms]

or could some of these fit into the minor procedures (hopefully with risks/benes) category under risk?

Yes, I believe they do if the risk was mentioned in the notes and taken into account, even if it was an order and not performed because it had a play in the MDM. I suppose I am answering my own question if there is an actual order for a diagnostic procedure, not a referral but an actual order, then it should count towards the analyzed data category.