E/M Coding MDM Clarification: Lab Ordered and Reviewed — One Point or Two?

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E/M Coding MDM Clarification: Lab Ordered and Reviewed — One Point or Two?

Medical coders often struggle with the Medical Decision Making (MDM) data table in E/M coding. One of the most debated points is:

If a lab test is both ordered and reviewed, does it count as one point or two?

MDM scoring determines the level of service — and over‑counting can lead to upcoding risks, while under‑counting can reduce legitimate reimbursement. Let's see how to calculate this and the supporting guidelines.

The AMA CPT E/M Guidelines

AMA Guideline states: “Tests are counted once per unique test, even if ordered and reviewed. Ordering and reviewing the same test is not counted separately.”

  • CBC ordered and reviewed → 1 point
  • CBC ordered + X‑ray ordered and reviewed → 2 points (one for each unique test)
  • CBC ordered + external lab report reviewed (from another provider) → 2 points (because external data review is a separate element)

Why Double‑Counting Is Risky

Considering points for both order and review of the same test is double dipping. This can:

  • Inflate MDM scoring.
  • Lead to audit penalties.
  • Create compliance risks for providers and coders.

Special Note on Reviewing Prior Lab Results

The AMA CPT 2021 Guidelines clarify that only tests ordered and/or reviewed during the current encounter count as data points. Reviewing previous lab results from earlier encounters does not add new points in the MDM table.

However, in practice, some clients or providers may document prior labs (e.g., ALT, HbA1c) as “reviewed” in the current encounter. If the provider explicitly states that reviewing those prior results influenced medical decision making for the present visit, some organizations may choose to count them.

Compliance Perspective

  • Strict AMA/AAPC interpretation: Prior labs reviewed = no point (unless external data).
  • Client practice: If documentation shows clinical relevance (e.g., HbA1c trend reviewed to adjust diabetes medication), some clients may count it.

Coders should clarify with their client whether to follow national guidelines strictly or internal policy. If the client requires counting prior labs, ensure documentation clearly supports medical decision making to reduce audit risk.

Key Takeaway

  • Same lab ordered + reviewed in current encounter = 1 point.
  • Prior labs reviewed = 0 points (officially), unless client policy allows with clear documentation.
  • Always distinguish between guideline compliance and client workflow expectations.

References

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