Wiki Test ordered and reviewed 2021

[RABBIT2020]

" Patient declined repeat testing for flu, strep and covid because he has been testing at home himself."
Would this be considered 3 tests for moderate level?
Pt presented with sore throat for 7 days. Dx. was uri with medication prescribed.
Outpatient office visit.

Please give your viewpoint.

 

[OpenClaims]

If the patient declined the testing, then no, this wouldn't count toward anything assuming that the provider did not actually put the orders through.

 

[RABBIT2020]

If the patient declined the testing, then no, this wouldn't count toward anything assuming that the provider did not actually put the orders through.

I favor your response since there was no order for the tests.
My supervisor wants it to be counted as 3 tests for moderate data points. This way we can have 2 of 3 since rx was prescribed for an overall of 99214 moderate level....

 

[csperoni]

If the patient declined the testing, then no, this wouldn't count toward anything assuming that the provider did not actually put the orders through.

I disagree. From the AMA 2021 outpatient guidelines:
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. 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. 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.

The test does NOT need to be "ordered" in the EMR system to count. The same logic applies to surgery. If the provider is recommending a surgery, but the patient refuses, you may count decision for surgery in risk.

 

[OpenClaims]

Interesting. My superiors have advised our coding team otherwise.

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. 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. 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.

The test does NOT need to be "ordered" in the EMR system to count. The same logic applies to surgery. If the provider is recommending a surgery, but the patient refuses, you may count decision for surgery in risk.

 

[csperoni]

Interesting. My superiors have advised our coding team otherwise.

That's why whenever I can, I like to quote references. I cannot tell you how many times in my life I've heard the "this is the way we always do it" with nothing to back it up. And it turns out they've been doing something not quite correct for years. If the AMA tells me in black and white that I can count tests considered, but not ordered, then I am counting them.