If a patient comes in and a urinalysis (UA) is ordered and performed, can it be counted as data reviewed and/or analysis?
If the practice is billing for the UA, then you should NOT count it in the data reviewed and/or analysis. The 2021 CPT® book (E&M Services Guidelines Page 8) states “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.” If you perform a UA in the office, and BILL for it, you don’t include it in medical decision making.