When may a physician or other qualified health care professional (QHP) use in-house laboratory tests (ie, rapid strep, rapid flu, complete blood count [CBC], rapid severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease 2019 {COVID-19}]) and testing as data elements toward MDM selection? ...
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Article Overview
This article covers guidance on using in-house and point-of-care laboratory tests as data elements for evaluation and management (E/M) medical decision making. It is aimed at physicians, qualified health care professionals, and coding/billing staff who need to understand how testing, ordering, and review are treated under CPT guidance and related AMA technical corrections.
Why This Topic Matters
Understanding how common office-based tests fit into MDM selection helps support accurate E/M level determination and consistent documentation practices. The article also clarifies how separate reporting considerations can affect whether a test is counted as part of the MDM workup.
What You Will Learn
- How point-of-care and in-house testing is discussed in relation to E/M medical decision making
- Which general categories of laboratory and diagnostic tests are addressed in the guidance
- How CPT and AMA guidance frame ordering and review of tests in the MDM context
- How separate professional component reporting can affect whether a test is considered for MDM
Who Should Read This
- Physicians
- Qualified health care professionals
- Medical coders
- Coding auditors
- Practice managers
- Clinical documentation staff
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