Q&A: Can ordering tests impact E/M level?

Q: A nurse practitioner told a patient to return after an office visit if his chest pain worsened, and the provider ordered a nuclear stress test to take place the next day. Can my provider count the plan for the stress test in the medical decision-making for the previous encounter, even if the diagnosis isn’t made until eight days after the face-to-face encounter?

A: The very fact that your provider has ordered a test can impact the medical decision-making element of an E/M service, and that’s something you can attribute to the day-of encounter, advises Maxine Lewis, president of Medical Coding and Reimbursement in Cincinnati.

Lewis points to the medical decision-making section, including the table of risk, within the E/M documentation guidelines as a frame of reference. Among the factors used to determine the correct level of medical decision-making is “the amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed,” the guidelines state (see resource, below).

In the scenario outlined above, “the nurse practitioner had to make that decision during the current encounter, not necessarily having to wait for the results,” Lewis says.

Also, the table of risk specifically mentions a cardiac stress test in the moderate diagnostic procedures column, so this type of test would contribute to the level of medical decision-making. Ultimately, despite not having results from a test, “it will contribute to a higher level of medical decision-making when the procedure is ordered,” Lewis says.

Editor’s note: This answer was provided based on limited information and first appeared on Part B News. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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