tci General Surgery Coding Alert - 2023 Issue Q3

You Be the Coder: Consider Test Order for MDM

Question: During an office visit, the surgeon ordered specific lab tests for inflammation and H. Pylori infection to help determine the need for an EGD. The patient refused to complete the lab work. Should the surgeon still include the lab test order when determining the complexity of the encounter? Illinois Subscriber Answer: Yes, you should factor the surgeon’s order for a diagnostic test into the medical decision making (MDM) or the care/treatment plan. Ensure that you have documentation of the test order, and preferably, an indication that the patient refused the test. Here’s why: The physician’s...

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