Wiki offered vs ordered

[RABBIT2020]

When the doctor documents that medication was offered and patient declined does this qualify for medication management?

Likewise if the doctor documents that an xray was offered. Patient declined; prefers to see pmd first. Can this be counted for a data point.

Note in both questions the md says offered not ordered.

 

[csperoni]

Yes. If the physician is documenting what is being considered, it may be counted, even if it ultimately did not result in an order. From the AMA 2021 E/M Outpatient guidelines:
"Ordering a test may include those considered, but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented."
and
"The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is
palliative treatment."