tci ED Coding & Reimbursement Alert - 2007 Issue 11

READER QUESTIONS: Diagnostic Decision Should Figure Into E/M Level

Question: A patient reports with a severe headache and blurred vision. During the course of an E/M service, the physician prescribes pain medication for the patient. Suspecting a migraine, the physician recommends the patient undergo a computed tomography (CT) scan. The patient refuses the CT scan, saying she-d prefer to try to -get by- with the pain medication. When determining the E/M level for this service, should I give the physician credit for the CT scan order?Iowa Subscriber Answer: You can factor the physician's order into the medical decision-making--but make sure he documented:- that he ordered the test...

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