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Thread: Mdm ?

  1. #1

    Default Mdm ?

    AAPC: Back to School
    I have a question about the MDM for the amout/complexity of data part. My doctors order an x-ray and does the x-ray in the office and read and interpt the x-ray. We bill for the x-ray. Can we get a point for CPT radiology section order and reviewed plus 2 points for independent interpreation of an image, tracing and speciman. For a total of 3 points for this section?

    The reason I am asking is I was reading over slides from Stephanie Jones who is a presenter for AAPC. One of her slides show if a physician needs to make an independent visualization and interpreation(for ex, MRI film) and he or she is not billing separately for this service, it too is credited to this componet of code selection. All the audit forms I have does not say this they just say independent interpreation of a image, tracing, speciman.

    Thank you
    Last edited by coder21; 04-16-2009 at 06:18 PM.

  2. #2
    Join Date
    Apr 2007


    If our docs say that they personally reviewed and interpreted the x-ray or even the EKG, we allow the 2 points for that. They may not be the one doing the "official" read of the x-ray even.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  3. #3


    Are you billing for the x-ray or the ekg also?

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Billing is immaterial

    Whether or not I code out/bill for the reading of the X-ray, ultrasound, etc is immaterial to whether it counts as part of the MDM for the E/M service.

    If the physician independently reviews the data, I give the additional data points in determining MDM.

    F Tessa Bartels, CPC, CEMC

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