Primary Care Coding Alert

Question: An established patient reports with a severe headache and blurred vision. During the course of an E/M service, the FP prescribes pain medication for the patient. Suspecting a migraine, the physician recommends the patient undergo a computed tomography scan. The patient refuses the CT scan, saying she-d prefer to try to -get by- with the pain medication. When determining the E/M level for this service, should I give the physician credit for the CT scan order?

Iowa Subscriber

Answer: You can factor the physician's order into the medical decision-making -- but make sure he documents:

• that he ordered the test
• that the patient refused the test
• why the patient refused the test.

Also, factor the physician's choice to run a CT scan into your E/M level, because the physician made a medical decision to run the test -- even though the patient ultimately declined the service.