Answering Your Questions about Lab Tests

July 3, 2023

In this week’s Coffee & Coding, we tackle an intriguing question posed by a reader—a question that I’m sure many of us have contemplated at some point:

Can lab and radiological tests that are ordered and subsequently read count toward the data section in MDM (Medical Decision-Making)?

The straightforward response is No.

However, let’s explore the topic in more detail with insights from the American Academy of Professional Coders (AAPC):

“According to the American Medical Association (AMA), the ordering and actual performance and/or interpretations of diagnostic tests/studies during a patient encounter are not included in determining the level 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.”

What if the other physician who ordered the labs and reports separately is a colleague in the same medical specialty as you?

According to the American Academy of Family Physicians (AAFP):

“You may count review of data separately ONLY if the tests were ordered by an external physician—one who is not in the same group practice or is in a different specialty (e.g., an Emergency Department physician orders a chest x-ray and labs that are then reviewed by a family physician during a follow-up visit).”

“It is assumed that the physician or other qualified health professional (QHP) would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test.”

2021 E/M Guidelines FAQ – May – AAPC Knowledge Center

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coders@calmwatersai.com!

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