A patient is seen by a physician or other qualified health care professional (QHP) in a cardiology clinic where recent laboratory results (not billed by the clinic or physician) are documented or reviewed and counted as data elements for determining the E/M level of medical decision making (MDM) for all E/M office codes ( 99202 - 99205 , 99212 - 99215 ). The patient returns a month later and is seen by a different physician in the same specialty and clinic. May this second physician count data elements for review and assessment of the laboratory results regarding the patients current condition as an element of MDM? ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article addresses a common E/M documentation question involving laboratory results and medical decision making in an office or clinic environment. It is aimed at physicians, QHPs, coders, and billing staff who need to understand how prior review of test data affects subsequent encounters when more than one clinician in the same specialty or medical group is involved. The discussion focuses on broad guidance for counting data elements in E/M office visits and the distinction between prior review, later review, and review from outside a clinician’s specialty or group.

Why This Topic Matters

Understanding how laboratory results are handled in E/M medical decision making helps support accurate office visit reporting and consistent documentation across clinicians in the same group or specialty.

Codes Discussed

• CPT: 99202
• CPT: 99203
• CPT: 99204
• CPT: 99205
• CPT: 99212
• CPT: 99213
• CPT: 99214
• CPT: 99215

Code Ranges Discussed

• CPT: 99202-99205
• CPT: 99212-99215

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