General Surgery Coding Alert

Question: Can we count a provider’s efforts to counsel a patient against a test as evaluation and management (E/M)? For example, a patient comes in wanting magnetic resonance imaging (MRI) but has no symptoms or signs or family history that warrant the test. While we could provide it, the provider says it’s not medically necessary and spends time telling the patient why. Can we count this, even though it didn’t happen?

Alabama Subscriber

Answer: This type of discussion could indeed impact the E/M level of service, according to the AMA.

On pages 6-7 of its Evaluation and Management Services Guidelines, AMA says: “Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented.”

So, as long as you provide detailed and relevant documentation, you should be able to justify the provider’s time and efforts in the E/M level.

But remember. The patient must have some sort of chief complaint — a medically necessary reason — for the visit,

which must be documented in the chart. If the patient fears a problem that does not exist, for example, you could document F45.21 (Hypochondriasis) or Z71.1 (Person with feared health complaint in whom no diagnosis is made).