Neurology & Pain Management Coding Alert

Emergency department (ED) encounters can be tricky to code because they’re likely not as familiar as office/outpatient encounters for most practices.

ED encounter coding is also complicated by the potential variability of each patient’s situation and whether or not you can include diagnostic tests on your claim.

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

Consider Counting 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 medical decision making (MDM) or care/treatment plan when deciding your overall ED evaluation and management (E/M) code level. Remember, you’ll report a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) set when your provider performs an ED E/M.

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 (medical decision making) 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.

Example: A patient with a history of migraine presents to the emergency department 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 they feel much better and want to 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.