Test Result Review Coding

August 1, 2008

I would like to know what CPT and ICD code to use in case of a visit for test result review.

Question: I would like to know what CPT and ICD code to use in case of a visit for test result review.

Answer: In most cases, payment for physician management decisions based on lab results are included in your fee under the medical decision-making component of an E&M service; it can’t be billed separately.

Now, if you are meeting the definition of an E&M visit, doing some HPI, review of systems, and medical decision making at that visit which is unique, you can bill the E&M. I suspect you are not doing all this, however. You are just telling the patient about the results.