Urology Coding Alert

Question: Sometimes my urologist orders a diagnostic test — such as urinary flow, postvoid residual urine, or prostate-specific antigen (PSA) test — for benign prostatic hyperplasia (BPH) screening or a surgical procedure, but the patient refuses to undergo the test or procedure. The urologist documents the request for the test/procedure and the medical necessity for the order. Should the physician still get credit for the order when determining the complexity level associated with the encounter even though the patient did not proceed with the test or surgical procedure?

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Answer: Yes, you should factor the physician’s order into the medical decision making (MDM). Your physician’s decision to order a diagnostic test or recommend surgery is part of their MDM, whether or not the patient complies. Your urologist 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 or procedure, 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 E/M guidelines, “ordering a test may include those considered not selected after shared medical decision making.”