Cardiology Coding Alert

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?

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Answer: You should factor the physician’s order into the medical decision making (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 can impact each of the complexity (MDM) section’s three elements. Physicians frequently recommend a test, but the patient declines for various reasons (for example, financial concerns or reservations about risks).

Factoring in the physician’s order makes sense because if the physician went through the MDM process to determine that the patient needed a particular test, even though the patient didn’t follow through, the physician should receive credit for that, provided there is documentation of that thought process.

Although the historic elements of history and physical exam no longer contribute to the level of E/M code selection in 2023, a medically appropriate history and/or physical exam must still be documented, and it informs the MDM choices as to what the physician does (or doesn’t do) to determine the diagnosis and treatment plan.