Counting Labs Done “In House”

We’ve been seeing this question posted searching for authoritative references.

My clinic bills the 81003 for a UA done in house and A1C and prothrombin. My understanding is that it can NOT be counted as a unique test ordered under current guidance but I can’t find where the AMA says this.

Here is what the AMA 2021 CPT(R) Manual says.

Any 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 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 reported separately.


Dr. Vinita Magoon, DO, JD, MBA, MPH, CMQ replies to similar questions in his 2021 outpatient office E/M changes FAQ (Nov 6, 2020) n the AAFP’s FPM Journal.

Is use of over-the-counter (OTC) medications automatically considered low risk (as it was under previous guidelines)?

OTC drugs are not necessarily without risk and therefore are not necessarily considered low risk for purposes of MDM. For example, recommending an OTC medication to a patient with several co-morbidities may still result in a detailed discussion of risk. Therefore each instance should be evaluated individually and not automatically characterized as low risk.

If I order a test during one visit and review the same test during the next visit, can I count this as a data point for both visits?

No, you can only get one point for this lab, so the order and review of results is part of the data ordered/reviewed during the first visit. It is not considered a unique data point in a subsequent encounter. When you order a test it is assumed you will review it, therefore both the ordering and the reviewing is attached to the first visit. 

If I review a previous A1c and order a new A1c during the same encounter, does this count as two points under data reviewed?

No. Each unique test will count as one point and a unique test is defined by its CPT code. Since this is the same test with the same CPT code, the reviewing of the previous test and ordering of the new one will together count only as one point.


Novitas Solutions’ addresses this question in their Evaluation and management FAQs

15. Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?

Per AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. 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 (i.e., 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 to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.


In an article for AAOS, Margaret M. Maley, BSN, MS of KarenZupko & Associates, Inc. (KZA) writes:

Data are divided into three types:

  1. tests, documents, orders, or independent historian(s) (with each unique test, order, or document counted to meet a threshold number)
  2. independent interpretation of tests
  3. discussion of management or test interpretation with external physician or other QHP or appropriate source

Data include information obtained from multiple sources, interprofessional communications, and interpretation of unique tests. To be considered part of MDM, these data elements cannot be reported separately with a CPT code for reimbursement. [bold font is our emphasis]

For example, if reporting the professional component of a radiologic service, you cannot also count the independent interpretation of the radiograph as a data element in MDM—no double-dipping. A unique test is imaging, laboratory, psychometric, or physiologic data defined by a CPT code. For example, when you order radiographs, three views of the hip and three views of the knee would be considered ordering two unique tests, as each of those radiologic series has its own CPT code.


What other complex scenarios are you running into?

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