tci E/M Coding Alert - 2023 Issue Q2

Reader Questions: Recognize When ‘Reviewed’ is Tethered to an Order

Question: If the provider orders a test, does her review of that test during the follow-up encounter count as a “data element reviewed” when I’m leveling the visit using medical decision making (MDM)? Michigan Subscriber Answer: This is a common source of confusion. Simply put, the review of the test does count toward MDM, but it’s included in the order and therefore cannot be counted as separate from that order. Using the provider’s review of the test toward the data element for MDM is considered double-dipping. CPT® guidelines say that the test’s review &ldquo...

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