Outpatient Facility Coding Alert - 2023 Issue 6
Reader Questions: Account for Work This Way on Refused Test
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Article Overview
This reader Q&A discusses how to think about a diagnostic test that was ordered but not completed because the patient refused. It focuses on E/M medical decision making, the importance of documenting the order and refusal, and the role of CPT® 2023 guidance in understanding what counts toward encounter complexity. The article is aimed at coding and billing professionals who need to evaluate documentation for office, ED, or other E/M services.
Why This Topic Matters
Refused tests can change how encounter documentation is interpreted, so coders and auditors need to know when a physician’s work still supports the documented level of service. Clear documentation affects accurate E/M code selection and compliance with current guideline language.
What You Will Learn
- How a refused diagnostic test is addressed in E/M documentation
- Why documentation of the order and refusal matters
- How medical decision making relates to ordered but uncompleted tests
- How current CPT® E/M guidance frames test ordering in shared decision making
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians
- Billing staff
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