In the 5th Edition of "Frequently Asked Questions in Obstetric and Gynecologic Coding" published by the American Congress of Obstetricians and Gynecologists, the following question is posted on page 3.
Question: If I dictate "exam deferred per patient request" can this be counted towards the examination requirement of E/M?
Answer: Yes. When the patient defers the examination it is appropriate to count it as if it were performed. The examination cannot be counted if it was deferred by the physician. The physician's dictation must specifically state that the "examination was deferred per patient request" to fulfill the documentation requirement.
I disagree that we can count something, using the point-based auditing system, which was not done.
You can count it but it should not exceed the MDM for that visit.
Per the AAPC: MDM is the overriding determinant of the level of service, and a billed service level should never exceed the MDM reflected in the documentation. Be familiar with your Medicare intermediary’s criteria for evaluation of MDM and apply those criteria stringently to your provider’s records. If you meet Medicare criteria consistently, then the records should easily fulfill criteria for private insurers.