decisionhealth Newsletters, Part B News - 2018 Issue 10 (October)
Ordering tests can up the level of medical decision-making, even pending results
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Article Overview
This Find-A-Code article discusses evaluation and management documentation, with emphasis on how diagnostic testing orders may affect medical decision-making before test results are reported. It is aimed at coders, billers, and clinical documentation staff who need to understand how current-encounter decisions are reflected in E/M support. The piece references Medicare E/M documentation guidance and general risk-table concepts tied to test ordering.
Why This Topic Matters
Understanding how pending diagnostic tests factor into E/M documentation helps support accurate service level selection and better alignment between the encounter record and the medical decision-making performed.
What You Will Learn
- How diagnostic test ordering can be reflected in E/M medical decision-making documentation
- How E/M documentation guidance frames the amount and complexity of data reviewed or analyzed
- How risk-table concepts relate to test ordering during an encounter
- Why timing of test results may differ from the documentation impact of the order
Who Should Read This
- Medical coders
- Billing staff
- Clinical documentation specialists
- Nurse practitioners
- Physician practices
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