When Can the Amount and Complexity of Data Apply to Lab Tests?
April 22, 2024
It’s a great question—and one that generates discussions in almost every medical office. In this issue (and next week’s, too), we’ll examine some scenarios that will help you clarify the rules.1
Preventive Medicine Service Visits (99381-99397)
Generally speaking, labs and other tests ordered during these visits may not be counted toward medical decision-making (MDM). That’s because you use these codes to report preventive services, and the 2021 CPT changes do not apply to these services.
But there are always exceptions to the general rule. For example:
- During the “preventive” visit, the provider discovers an abnormality that merits enough additional work to meet the criteria for a problem-oriented E/M service; or
- The provider addresses a pre-existing medical problem during the preventive services visit.
In both of these cases, lab tests could help determine the appropriate level of MDM, and you could apply office codes (99202-99205) or outpatient codes (99211-99215). Additionally, you should include modifier 25 to indicate that you delivered a significant and separately identifiable E/M service on the same day as the preventive service.
Review of Tests or Lab Results from an Outside Specialty Provider
In this case, a provider’s review of test results (e.g., EKG) and a specialist’s notes can apply to the “amount and complexity of data” element in MDM, provided the tests and notes came from a “unique source.” So what counts as a “unique” source? For that, we have to turn to the E/M 2021 Errata and Technical Corrections, CPT 2021. It defines a unique source as a physician or qualified healthcare professional in a distinct group or different specialty or subspecialty, or a unique entity. You can also apply a “unique test,” which is defined by the CPT code set. When you compare results of the same unique test during an E/M, count it as one unique test. The same principle applies with all materials reviewed from a unique source: Count it as one element in MDM.
Next week, we’ll review more scenarios.
1American Medical Association, CPT Evaluation and Management Revisions FAQs: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management-em-revisions-faqs
Got a question about E/M coding? We’d love to hear from you.
Submit your questions by emailing us at coders@calmwatersai.com
Michelle Sergei-Casiano CPC, CFPC, CEMC, CPMA Senior Manager, Regulatory and Coding Compliance coders@calmwatersai.com