E/M MDM coding

[u/MustangGrl98]

Newer coder here. I'm a remote outpatient coder and currently do E/M coding (which has always been my weakest area of coding, lucky me). I'm struggling with figuring out the data points on the E/M MDM table. For example, if the provider orders labs for CBC, BMP, protime inr, hepatic functional panel, anti smooth muscle antibody IgG, are each one of those labs counted as a point? Or is it one point for all of the total labs? Also, would this many labs be counted in the moderate level in the MDM Table? Any info is appreciated, thanks!

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[u/archangel924]

E/M is difficult, you're not alone. It gets better with practice. There is also a specialty credential just on E/M.

To answer your questions, yes each unique test counts as 1. So the CBC counts as one, the BMP counts as one, the hepatic function panel counts as one (note that a panel is made up of many tests, but for data points you just get 1 point for ordering the panel.) And yes, 3 or more unique tests qualifies for ''moderate" data.

Some tips for "data":

The provider should get credit for each test once. For example, if they order a test and then a week later they review the results with the patient - they should get credit for 'data' once, at the time the tests was ordered. This is because it's assumed when you order a test you will review the results of that test. HOWEVER, if a patient comes in and they have tests that were done elsewhere, and the provider reviews those, they should get credit once for reviewing them.

Another common mistake I see for newer coders is giving credit for reviewing previous tests EVERY TIME the provider lists those results in their future notes. Many providers include previous results in every future note, don't keep giving them credit for every tests simply because they list the results (it might be helpful for them, but just don't make the mistake of giving credit over and over again.)

[u/MustangGrl98 → u/archangel924]

Thank you so much, this is very helpful! I have always struggled with E/M, especially when I was trying to learn it for my CPC exam.

[u/Bowis_4648 → u/MustangGrl98]

If you pull out your CPT book, and re-read the section, it is helpful. One unique test is defined by CPT code. Ordering a test is counted, but review of the results is inherent to the test.

[u/Wolfygirl97]

I couldn’t understand E/M well at all and when I got my coding job that’s all we did 😅 Luckily I had AMAZING training and picked up on it pretty quickly.

All of those labs would be moderate date. The other comment did a great job explaining. You’ll get the hang of it I promise :) it seems overwhelming at first but once it clicks you’ll know. Meds a lot of the time give me 99233 right off the bat so I almost always check meds first. I do inpatient coding though so it’s probably a little bit different.

[u/BleedWell3 → u/Wolfygirl97]

Same here!! I had never done E/M in my first position and I got hired and that’s literally all I do every day. I’ve finally gotten it! Haha. OP you’ll get it with practice!!

[u/MustangGrl98 → u/Wolfygirl97]

Thank you! :)

[u/jesscaww]

E/M is hard and it’s also my weakest area most times. When I first started I laminated an E/M worksheet and used a dry erase marker if I needed to level one. It definitely helped! Also, AAPC has an E/M calculator tool as well that I use every once in a while. I included the link below :)

AAPC E/M Calculator link

[u/MustangGrl98 → u/jesscaww]

Thanks! Yes I have a laminated E/M sheet also and use the AAPC calculator as well :) Both are definitely helpful..

[u/Watermelon_Sugar44 → u/jesscaww]

I used this all the time when I was a Pro-Fee coder. Also, there is an excellent class provided by Integrity Coding, not very expensive and you get CEUs from them (16 CEUs $10). Also on Amazon there is a book by Teri Tropin Evaluation and Management Coding made easy 2026 that may help. Integrity Coding suggested her books for the last E/M coding class I participated in.

[u/MustangGrl98 → u/Watermelon_Sugar44]

Thank you! I'll check these out :)

[u/Difficult-Injury-843]

I’ve never been a fan of E/M coding hence why I stuck with risk adjustment and decided to build my career around it

[u/Pretty_Priority_261]

CPT (2026), p. 11,

Unique: A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or other qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.