Medicare Compliance & Reimbursement - 2023 Issue 7
You Be the Coder: Consider Test Order for MDM
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Article Overview
This Q&A article discusses office-visit documentation and evaluation and management medical decision making when a physician orders diagnostic testing as part of assessing a condition, but the patient does not complete the testing. It is aimed at coders and billing staff who need to understand how documentation of orders, refusals, and clinical reasoning can affect encounter complexity. The article focuses on general E/M documentation principles and the relationship between the care plan and MDM.
Why This Topic Matters
Accurate documentation review is important when a recommended diagnostic test is ordered but not performed, because the note may still support the visit’s complexity if the reasoning is clearly recorded.
What You Will Learn
- How diagnostic test orders relate to medical decision making
- Why documentation of a patient’s refusal matters
- How office visit documentation supports evaluation and management coding
- How the 2023 E/M framework treats history and physical exam in relation to MDM
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physician practice administrators
- Surgeons
- Evaluation and management documentation specialists
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