Ophthalmology and Optometry Coding Alert

Question: During an office visit, the ophthalmologist orders optical coherence tomography angiography (OCT-A) to determine the presence and severity of diabetic retinopathy. We don’t have the equipment to perform OCT-A, so the patient was referred to an outside facility. However, the patient refused to complete the imaging test. Should we still include the imaging test order when determining the complexity of the encounter?

Nevada Subscriber

Answer: Yes, you should factor the ophthalmologist’s order into the medical decision making (MDM). Your physician’s decision to order a diagnostic test is part of their MDM, whether or not the patient complies. Your ophthalmologist still went through the process of considering risks, alternatives, treatment options, etc., and should get credit for that work.

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.

Physicians frequently recommend a test or procedure, but the patient declines for various reasons (for example, financial concerns or reservations about risks).

CPT^® 2023 specifically states in the evaluation and management (E/M) guidelines, “ordering a test may include those considered not selected after shared medical decision making.”