Oncology & Hematology Coding Alert

Question: I know that CPT^® guidelines state we cannot count a test toward an evaluation and management (E/M) visit when the practice bills for the test. But what happens when a provider documents their considerations for a test and then simply states that they didn’t do those tests because they weren’t needed? For example, would a statement such as “I considered X-rays, but no indication for X-rays” be sufficient to count as a data point for the amount and/or complexity of data to be reviewed and analyzed element of medical decision making (MDM)?

AAPC Forum Participant

Answer: While it is possible to count tests not ordered as an MDM data point, the provider’s documentation must go beyond the kind of statement you presented. If a provider stated, “I didn’t order cancer medications because the patient doesn’t have cancer,” you would not give credit for prescription drug management. Similarly, you cannot count not ordering a test when there is no need for the test.

In situations like this, CPT^® guidelines do allow you to count tests considered but not ordered if the provider documents medical necessity for the test and then the provider or the patient decide that the test cannot be performed because the risk to the patient is too great or the benefit to the patient would not be sufficient to justify it. Or, as CPT^® puts it:

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, in situations like this, you should consider documentation based on statements like the following:

Example statement 1: “I considered an MRI of the abdomen and pelvis, but after an examination, I don’t believe an MRI is necessary at this time unless pain continues for at least 2 weeks.” This statement would illustrate the thought process the provider demonstrated to determine testing was not necessary. In this case, the documentation would justify counting an MDM data point toward the overall MDM level.

Example statement 2: “I considered an MRI for optimal diagnosis and treatment, however patient states she is extremely claustrophobic and would prefer alternate imaging. Ordered X-ray 2 views instead.” This statement would enable you to count both the MRI and the X-ray (assuming, as you say, that you do not bill for the X-ray separately).