ED Coding & Reimbursement Alert - 2023 Issue 4
Reader Questions: Consider MDM for Tests Not Performed
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Article Overview
This reader Q&A discusses how to document and think about diagnostic tests that are ordered but not completed because the patient declines. It is aimed at physicians, coders, and auditors who need to understand how documentation supports medical decision making in E/M services. The article gives general guidance on what should be documented and why the physician’s thought process still matters when a planned study is not performed.
Why This Topic Matters
Clear documentation of ordered-but-refused testing can affect how encounter complexity is supported in the medical record and reviewed during coding or audit workflows.
What You Will Learn
- How ordered diagnostic tests that are refused by the patient relate to MDM documentation
- Why documentation of the physician’s thought process is important when a test is not performed
- How a clinical example illustrates the documentation issue in an E/M setting
- What elements of the encounter record should support the physician’s plan and concern
Who Should Read This
- Physicians
- Medical coders
- Coding auditors
- Compliance professionals
- Practice managers
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