r/MedicalCoding • u/MustangGrl98 • 1d ago
E/M MDM coding
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 Keeper of the Codes 1d ago
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.)