tci E/M Coding Alert - 2023 Issue Q2

Reader Questions: Consider MDM for Tests Not Performed

Question: Suppose a physician orders a diagnostic test, such as an electrocardiogram (EKG), but the patient refuses to undergo the test. Should the physician still get credit for the order when determining the complexity level associated with the encounter? Michigan Subscriber Answer: You should factor the physician’s order into the MDM or care/ treatment plan. Be sure that someone documents the fact that the physician ordered the test, but the patient refused it. If possible, you should also record why the patient refused the test. What you should know: Your physician’s decision to order a diagnostic test...

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