Neurology & Pain Management Coding Alert

You can receive MDM credit for test orders, even if the patient refuses the test

If you want to bolster you E/M coding, you'll have to communicate with your neurologists the essential information you need to award credit for diagnostic decisions, test ordering and review. Often, a few simple sentences in the patient note can make the difference.

The scoop: Neurology Coding Alert posed three questions about E/M guidelines to a CMS policy official who spoke with us on the condition of anonymity. Here's what we learned:

Collect Credit for Diagnostic Decisions

Question 1: Suppose your neurologist orders a diagnostic test, such as electromyography (EMG), 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?

CMS response: Factor the neurologist's order into the medical decision-making (MDM) or care/treatment plan. Be sure you document that the neurologist ordered the test, the patient refused it and why he did so.

What you should know: Your neurologist's decision to order a diagnostic test can impact each of the complexity (MDM) section's three elements, says Jim Collins, CPC, ACS-CA, CHCC, CEO of the Cardiology Coalition in Matthews, N.C. Physicians frequently recommend a test, but the patient declines for various reasons (for example, financial concerns or reservations about risks, pain, etc.).

Factoring in the physician's order makes sense because if the neurologist "went through the medical decision-making 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," says Sherry Wilkerson, RHIT, CCS, CCS-P, manager of coding and compliance for CHAN Healthcare Auditors in St. Louis.

Don't Dismiss HPI Elements

Scenario: A patient presents with frequent migraine headaches. The neurologist documents, "The patient's chief complaint is migraine headache, not exacerbated with any specific activity and has no reported associated symptoms."

Question 2: Should the neurologist receive credit for documenting the HPI elements of "modifying factors" and "associated signs or symptoms" even though he reported that no activity exacerbates the condition and no associated signs or symptoms exist?

CMS response: The neurologist should receive credit. What you've provided is valuable information, which the neurologist should document.

Tip: Don't let the neurologist document that the patient's HPI is "negative." Instead, if the patient has no exacerbating activities or associated symptoms, as in the above example, the physician should specifically state these conditions in the documentation.

For example, in the documentation, the neurologist writes, "The patient relays that her problems are not related to time of day, she relays no aggravating or alleviating factors, and there are no associated symptoms," Collins says.

Why writing it out helps: With this simple sentence, the neurologist would document three of the required four HPI elements (timing, modifying factors, and associated signs and symptoms) necessary to establish an "extended" HPI, Collins says.

When you also add in the documentation "an anatomic description of where the problem is (which should be possible for about every condition), you would firmly establish an extended level of HPI," Collins says.

Under the 1995 documentation guidelines, this level of history is necessary for any established patient visits above level three and any new patient visits or consults above level two.

Account for Image Ordering and Review Separately

Scenario: The Marshfield Clinic's audit tool (used by many carriers but not specifically endorsed by CMS) awards two credits for independently visualizing an image, tracing or specimen (not simply reviewing a report). The tool also awards one credit for ordering a diagnostic test.

Question 3: If the neurologist orders a test (such as a positron emission tomography [PET] scan), and he personally reviews the results on the same day, would he be awarded credit for both the order (1 credit) and the personal review (2 credits)?

CMS response: Yes. The order and personal review are two separate activities. If you order the PET scan, you might not get to review it. If you do review it and make judgments, then documenting this activity should allow you to have credit for both ordering and reviewing it (not just reading a report).

"This response is an important clarification for physicians who personally review their own diagnostic tests [including imaging procedures such as PET scans and magnetic resonance imaging]," Collins says.

In a nutshell: You should understand that for the audit tool's complexity section, you only need four credits in the data section to achieve a "high" level of medical decision-making - as long as at least one of the other complexity section elements (diagnoses/treatment options or table of risk) also supports this level of complexity.