Under Category 2 for Moderate or Extensive data, which statement is true about interpreting tests when billing the CPT code for interpretation?

Under Category 2 for Moderate or Extensive data, which statement is true about interpreting tests when billing the CPT code for interpretation?

• A. The interpretation counts toward MDM.
• B. The interpretation cannot be counted toward MDM, but a form of interpretation should be documented.
• C. Independent interpretation is required for MDM.
• D. It must be reported as a complete test report to count.

Answer: (B)

The key idea here is how data are counted toward medical decision making when using Category 2 data for Moderate or Extensive data. In this category, the act of interpreting the test results itself does not count toward MDM. However, you still need to include some form of interpretation or summary in the medical record to show you engaged with the data and used it in your decision making. That’s why the statement about not counting the interpretation toward MDM, but still documenting an interpretation, is the correct one. In other words, you review and interpret the data as part of forming the plan, but the explicit interpretation itself isn’t a separate MDM data point under Category 2. A complete test report isn’t required to count toward MDM, and independent interpretation isn’t mandated for MDM in this context.

The key idea here is how data are counted toward medical decision making when using Category 2 data for Moderate or Extensive data. In this category, the act of interpreting the test results itself does not count toward MDM. However, you still need to include some form of interpretation or summary in the medical record to show you engaged with the data and used it in your decision making. That’s why the statement about not counting the interpretation toward MDM, but still documenting an interpretation, is the correct one.

In other words, you review and interpret the data as part of forming the plan, but the explicit interpretation itself isn’t a separate MDM data point under Category 2. A complete test report isn’t required to count toward MDM, and independent interpretation isn’t mandated for MDM in this context.