Point-of-care (POC) testing is common in today’s clinical setting, but it’s also one of the most frequently misunderstood components of E/M coding. A common misconception is that every POC test performed automatically counts toward the Amount and/or Complexity of Data to Be Reviewed and Analyzed. In reality, that’s not what the CPT guidelines say.

What the CPT Guidelines Say

The CPT E/M guidelines define data as the review and analysis of tests, not simply their performance.

This means that performing a point-of-care test alone does not automatically contribute to the MDM data element.

For a POC test to count toward data, the documentation should demonstrate that the provider:

• Reviewed and interpreted the test results.
• Incorporated those findings into the clinical decision-making for the encounter.

Simply listing a test result or documenting that a test was performed does not, by itself, satisfy the data requirements.

Why This Matters

Our auditors frequently identify encounters where POC tests are counted toward MDM even though the documentation only reflects that the test was performed or records the result.

This can result in overstating the complexity of medical decision making, potentially affecting E/M code selection and increasing compliance risk during an audit.

🔍 Audit Takeaway

When evaluating the MDM data element, remember that performance is not the same as analysis. Documentation should clearly demonstrate how the provider reviewed, interpreted, and incorporated the test results into patient care. Thoughtful documentation helps support accurate E/M code selection and reduces audit risk.

Each Auditor Insight is inspired by trends our auditing team is seeing in practice or by industry developments that have meaningful implications for coding, documentation, and compliance. Our goal is to help organizations stay informed, reduce risk, and code with confidence.

Reference: CPT® Evaluation and Management Guidelines, Amount and/or Complexity of Data to Be Reviewed and Analyzed