General Surgery Coding Alert

Question: During an office visit, the surgeon ordered specific lab tests for inflammation and H. Pylori infection to help determine the need for an EGD. The patient refused to complete the lab work. Should the surgeon still include the lab test order when determining the complexity of the encounter?

Illinois Subscriber

Answer: Yes, you should factor the surgeon’s order for a diagnostic test into the medical decision making (MDM) or the care/treatment plan. Ensure that you have documentation of the test order, and preferably, an indication that the patient refused the test.

Here’s why: The 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.