Wiki ED 2023 E&M guidelines - consideration for tests

[jbtrueba]

Now with the new guidelines, we can use the consideration for tests toward the overall MDM/E&M level. I often see providers documenting their considerations, but then simply state that they didn't do those tests because they weren't needed. For example: "I considered x-rays, but no indication for x-rays". Per ACEP's FAQ's, they explain how to quantify considerations......

• This includes consideration of further testing or treatment that may not be performed by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.
• the need to initiate or forego further testing, treatment, and/or hospitalization/escalation in care can be a factor in the complexity of medical decision making. Examples in which the physician/QHP may elect not to order a test, treatment, or management option include but are not limited to a clinician’s risk/benefit analysis or use of evidence-based risk calculators, or shared decision making

If I go by what ACEP details in their list of FAQ's as I showed above then the statement I used as an example would not truly be appropriate to use in the overall weight of the medical decision making. Does anyone else have a different view or any thoughts as to how you determine if you do or do not add a consideration to the overall mdm?

 

[csperoni]

Here's my take on it. Based on "I considered x-rays, but no indication for x-rays", I would not count the test. The provider is basically stating they didn't order it because there was no reason to. That would be like stating "I didn't order hypertension medications because the patient doesn't have hypertension."
However, a statement like "I considered MRI of left shoulder however patient states she is extremely claustrophobic and would prefer alternate imaging. Ordered left shoulder xray 2 views instead." In a situation like that, I would count BOTH the MRI and the xray.
Or "I considered MRI of abdomen and pelvis. Evaluated patient using ACR AC guidelines and MRI not indicated at this time unless pain continues for at least 2 weeks." That wording demonstrates that the provider used an evidence-based tool to determine testing not indicated.
I count data for tests considered when the are actually medically evaluated/considered. The documentation provided does not seem like it was actually medically evaluated/considered. It could also be poor documentation. Either way, I consider this an opportunity for provider documentation education.