The scoop: The Coding Institute posed four questions about E/M guidelines to a CMS policy official who spoke with us on the condition of anonymity. Here's what we learned: Diagnostics Impact Complexity Level 1. Question: Suppose a physician orders a diagnostic test, such as a colonoscopy, but the patient refuses to undergo the test. Should the physician still get credit for the order when determining the level of complexity associated with the encounter?
CMS response: You should factor the physician's order into the medical decision-making or care/treatment plan. Be sure you document that the physician ordered the test, the patient refused it and why he did so.
What you should know: Your physician's decision to order a diagnostic test can impact each of the complexity (medical decision-making) section's three elements, says Jim Collins, CPC, ACS-CA, CHCC, CEO of the Cardiology Coalition in Matthews, N.C. Physicians frequently recommend a test but the patient declines for various reasons (for example, financial concerns or reservations about risks).
Factoring in the physician's order makes sense because if the physician "went through the medical decision-making process to determine that the patient needed a particular test, even though the patient didn't follow through, the physician ... should receive credit for that, provided there is documentation of that thought process," says Sherry Wilkerson, RHIT, CCS, CCS-P, manager of coding and compliance for CHAN Healthcare Auditors in St. Louis, Mo.
Example: The physician performs a fecal-occult blood test (82270-82274) on a patient who complained of black tarry stools. When the test comes back positive, the physician orders a colonoscopy to determine the problem's source, but the patient refuses to take the test. "The physician needs to make note of this in the chart, not only as part of the medical decision-making," says Linda Parks, MA, CPC, CMC, CCP, of GI Diagnostic Endoscopy Center in Marietta, Ga.
2. Question: A patient presents with shortness of breath. The physician documents that "the patient's chief complaint is shortness of breath, which is not exacerbated with any specific activity and has no reported associated symptoms." Should the physician receive credit for documenting the HPI elements of "modifying factors" and "associated signs or symptoms," even though he reported that no activity exacerbates the condition and no associated signs or symptoms [...]