Outpatient Facility Coding Alert - 2023 Issue 3
E/M FAQ: Keep MDM Atop Your E/M Checklist
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Article Overview
This FAQ-style article is for emergency department coders, auditors, and clinicians who document evaluation and management services. It discusses how medical decision making is evaluated when a diagnostic test is ordered but not completed, and it reinforces the role of documentation in supporting the encounter record. The article is designed to clarify common uncertainty in E/M coding without providing a full coding tutorial.
Why This Topic Matters
MDM is a key part of selecting the appropriate level for ED evaluation and management services, so understanding how documentation of planned but refused testing fits into the record can affect coding accuracy and compliance.
Article Sections
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Calculating MDM for Tests Not Performed
Explains the article’s main topic: how ordered diagnostic testing that is not completed may still be relevant to the encounter record and MDM discussion. It also introduces the documentation issues surrounding patient refusal and provider reasoning.
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Example
Presents an emergency department scenario used to illustrate the broader documentation and MDM considerations discussed in the article.
What You Will Learn
- How the article frames MDM considerations in emergency department E/M services
- What kinds of documentation are discussed when a diagnostic test is ordered but not performed
- Why encounter documentation matters for reflecting provider assessment and plan
- How an example scenario is used to illustrate E/M documentation considerations
Who Should Read This
- Emergency department coders
- Medical coders
- Coding auditors
- Clinicians documenting E/M services
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