Receive E/M Credit for Declined Testing
Question: Can a provider receive evaluation and management (E/M) credit for counseling a patient against undergoing an unnecessary test? Recently, a 25-year-old patient who has a history of health anxiety was requesting a colonoscopy despite having no symptoms, risk factors, or family history that would warrant the procedure. The provider spent time explaining why the test was not medically necessary and discussed waiting until age 45 for normal screening recommendations instead. Is there any way to still receive credit for the time spent with the patient even though the provider performed no testing? AAPC Forum Participant Answer: Yes, you absolutely can. If you look under the Guidelines for Selecting Level of Service Based on Medical Decision Making (MDM) section of your CPT® code book you’ll find this passage: “The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately.” The guidelines provide information for determining when a test is considered part of an encounter: “Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Ordering a test may include those considered but not selected after shared decision making.” The guidance also mentions your situation specifically: “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.” So, as long as your documentation is thorough, it should support the provider’s time and work when determining the E/M level. Keep in mind that the patient must have some sort of chief complaint or medically necessary reason for the office visit. For example, as you mentioned, this patient has a history of health anxiety or hypochondriasis, so you could document F45.21 (Hypochondriasis). Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
