Urology Coding Alert

Reader Questions:

Lean on E/M Documentation for Services not Actually Performed

Question: Can we count a provider’s efforts to counsel a patient against a test as evaluation and management (E/M)? For example, a patient comes in wanting magnetic resonance imaging (MRI) but has no symptoms or signs or family history that warrant the test. While we could provide it, the provider says it’s not medically necessary and spends time telling the patient [...]
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