Wiki additional assessment not required vs additional assessment planned emergency room

[angeema]

I have read so many different views on this and it appears this is a grey area. Do diagnostic testing such as x-rays, ekg and labs performed during an emergency room encounter count as additional work-up, managemnet options on MDM? It seems if you do count this it would inappropriately elevate 99285. Such as situations when someone would come to the ER with anxiety....testings performed and Ativan administered, or alcohol withdrawal and Librium administered. Does anyone have a reliable source of information on this.

 

[amyjph]

I think your question is regarding the number of diagnoses or treatment options table in the MDM section? If the problem is new to the examiner, and there is additional workup planned you multiply the #x4 to get to either minimal, limited, multiple or extensive. However, this is only one of the three elements for getting the final result. This single element wouldn't necessarily bump it to a level 5 every time. Additionally, you would need to meet 3/3 of History/Exam/MDM for ED services 99281-99285. For 99285 you would need C/C/H.

Unfortunately, this seems to be interpreted differently depending on the payer. I disagree with the ones that don't allow credit for additional workup just because it was done at the time of the ED visit. Are they going to have the patient leave and come back? It's an ED visit. I follow the advice indicated in the AAPC handout below from NGS, Noridian, and Palmetto.

AAPC handout found while googling: http://aapcperfect.s3.amazonaws.com...6524/3a996cc7-1610-4cbc-b451-c6faf6e6fab1.pdf

• See info starting at page 21

Is your question is what is the definition of additional work-up? This is a good explanation of it from ACEP https://www.acep.org/administration...marshfield-clinic-scoring-tool-faq/#question8

• What qualifies as “additional workup planned” versus “no additional workup planned?”
  

  Answer​

  Because the MDM scoring tool has never been adopted or endorsed by AMA/CPT or CMS, there is no official coding policy or regulatory guidance that defines “additional workup planned.” However, with the understanding that the Marshfield E/M Documentation Auditors Worksheet was developed in and for an office-based practice, we can look to standards of practice in that setting to better recognize what may qualify as additional workup.
  When a patient presents to their primary physician/QHP with a new problem, the physician/QHP performs a history and physical exam appropriate for the chief complaint. In many cases, this will give the physician/QHP the information needed to determine a diagnosis and appropriate treatment. In more a complex case, the physician/QHP may order diagnostic tests; they may have the patient schedule an appointment with a specialist, they may prescribe a preliminary treatment with orders to return for re-evaluation or a variety of other options to get the information needed to establish a diagnosis and determine the appropriate treatment.
  If a diagnostic test is ordered during an office-based E/M service, samples for a lab test may be drawn during the encounter, but in many cases, the physician/QHP will arrange for testing at a lab, or the patient will be sent for x-rays, CT, MRI, etc. at a radiology center or outpatient department at a hospital. If consultation with a specialist is needed, that appointment will be arranged and scheduled for a later date. In both scenarios, the patient is scheduled for a return office visit to review the test results and/or consultation and discuss treatment options during a second E/M service. In an office-based practice, the MDM for these encounters would be scored as “additional workup planned.”
  In the emergency department, comprehensive diagnostic testing (lab tests, x-rays, CTs, MRIs, ultrasounds, etc.) is readily available to the patient during the ED encounter. The ED physician/QHP can request and receive a consultation from a specialist while the patient is in the ED. The patient can undergo a preliminary treatment regimen and be re-evaluated during the same encounter. The fact that this level of diagnostic and therapeutic intervention is provided during a single E/M encounter does not discount the severity or complexity of the “the number of possible diagnoses and/or the number of management options that must be considered.”
  In cases where the ED physician/QHP has efficiently assessed the number of possible diagnoses and/or the number of management options using the diagnostic and therapeutic interventions available to them, it seems reasonable to recognize the complexity of this process as “additional workup planned” when assigning value for this component of the MDM.
  

  ​

  • Is there a requirement for what type or how many ancillary tests, consultations, etc., must be ordered or obtained to be considered “additional workup planned?”
    

    Answer​

    Again, the MDM scoring is not part of the official coding policy from CPT or CMS, so there isn’t any guidance on determining what qualifies as additional workup planned. The MDM scoring for DMO is trying to establish when minimal, limited, multiple or extensive diagnoses or management options are considered.
    ED physician practices and their coders should determine what type or how many ancillary tests, consultations, etc., accurately indicate when there has been an extensive number of diagnosis or management options considered. It may not be appropriate to assign an extensive number of diagnosis or management options for a patient that solely received a single simple test, such as a strep test for a sore throat or a single x-ray for an ankle injury. Conversely, when a patient has labs and ultrasound for abdominal pain or an EKG and bloodwork for chest pain, it seems suitable that this level of diagnostic work indicates an extensive number of diagnosis or management options.​

  ​