ED Coding and Reimbursement Alert

See whether you know how to navigate this common ED scenario.

Calculating MDM for Tests Not Performed

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?

Answer: You should factor the physician’s order into the 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) in order to determine the diagnosis and treatment plan.

Example: A patient with a history of migraine presents to the ED with a headache that is worse than their usual pattern. The ED physician orders pain medication and a computed tomography (CT) scan of the head due to the atypical severity of the patient’s headache.

After receiving the pain medication, the patient declines the head CT, stating that she feels much better and wants to just go home. The physician urges the patient to go through with the CT scan and documents appropriate clinical and medical legal support for their concerns. Ultimately, the patient still refuses to undergo the test.

Even though the patient did not present for the study, the physician’s documentation reflects a higher level of concern, and that should be factored into the MDM.