By Carol Hoppe, CPC, CCS-P, CPC-I
MedLucid Solutions

As previously reported in a recent ISMA eReports, revisions were published by the AMA to the 2021 Evaluation and Management (E/M) office visit CPT^® code descriptors and documentation standards. These changes took effect Jan. 1, 2021. 

One area that physicians have asked about is the change to data ordered or reviewed. The revised guidelines state:

4Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately. 

The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels 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. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to3

This change indicates that you may count tests that are ordered and billed by the physician in the level of medical decision making (MDM) as long as there is no professional component or independent interpretation separately billed. This is a significant update that providers should be made aware of, as it could impact the level of service when coding based on MDM.

Indiana Health Coverage Programs (IHCP) has also published the changes in BT202120, dated March 23, 2021. 

For additional information, see the following AMA publications:

Overview of March 9, 2021, technical corrections (AMA)

Text of March 9, 2021, technical corrections (AMA)