Medicare Compliance & Reimbursement - 2007 Issue 11
READER QUESTIONS: Diagnostic Decision Should Figure Into E/M Level
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Article Overview
This short reader question and answer addresses evaluation and management documentation around a diagnostic test recommendation when the patient declines the service. It is relevant to coders, auditors, and clinical documentation staff who need to understand the general documentation elements discussed in the context of medical decision-making.
Why This Topic Matters
The article helps readers assess whether documentation supports the level of an E/M service when a diagnostic study is considered but not completed.
What You Will Learn
- How a diagnostic test recommendation can relate to evaluation and management documentation
- What general documentation elements are discussed when a patient refuses a recommended service
- How the article frames medical decision-making in this scenario at a high level
- The documentation context involved in a reader question about E/M leveling
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Physician practices
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