Mdm-coding edge mag jan 2011

Chino Hills
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I was reading over the article of Coding Edge for this month. As I was looking at Case Example #2 on page 24-25, I was troubled, I have read in previous articles and been told at a recent conference, that if lab work was not retrieved before end of encounter then it would be counted as additional workup. So for this example under MDM scoring was 3pt for new patient, no additional workup. Can anyone tell me as to why it would not be new problem w/ additional work up since I cannot tell that lab is back by the end of encounter. I do not see the results of CBC, CHEM 7 or the UA.



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I know how you feel!!! After attending my share of Coding Conventions and watching my Fellows teetering back and forth on the issue, I have decided that between CPT and Medicare DG's, "additional workup planned" is not beyond my comprehension.

I cannot believe a simple term like "planned" can be construed in in so many ways. How does this term get so many highly intellectual coders scratching their heads?

"A plan is typically any diagram or list of steps with timing and resources, used to achieve an objective." (wikipedia)

Since this is a development of "Marshfield Clinic" I would love for someone who helped to create this scoring system to explain what their intentions were. Otherwise, we should only interpret this in the literal sense. Also, I remember the very first Marshfield scoring sheet I ever saw and originally it read "additional workup planned/performed". What happened to the word "performed" and why can an omission of a term totally change our level of comprehension?

I'm actually looking forward to one of those extraordinary CMS auditors try to explain what their interpretation of "Additional Workup Planned" is. I would love to review their very own CMS DG's with them.

DG: For each encounter, an assessment, clinical impression or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

This implies that a key step of determining the Number of Dx or Management options begins with the providers very own "decisions" and not the end result of said decisions.

DG: The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies and medications..

That's right!- on the matter of Number of Diagnoses or Management options- CMS themselves includes a laundry list of "management options" that most coder's never consider when trying to determine "4pts vs 3pts in Box A". Have you ever considered patient instruction as additional workup planned? I bet NOT... And what is your interpretation of "Wide Range"? Certainly not as constricting as we have made it out to be.

DG: If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the regferral or consultation is made or from whom the advice is requested..

Bet there are very few coders who are counting case discussions as additional workup either...

In the area of Amount and/or Complexity of Data Reviewed, CMS DG's indicate:

DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled or performed at the time of the E/M encounter, the type of service (e.g., lab or x-ray) should be documented.

This is important.... It gives relevance to tests regardless of end result which is actually the real question at hand. If the DG was any more explicit it would be a crime. It could have read: If a service is performed and completed at the time of the E/M encounter, the type of service should be documented.

Anyway, sorry I'm so longwinded on this subject but it's an issue we all need to be versed in because sooner or later you will have a government auditor trying to explain what they think it is.

Finally, to answer your question: I absolutely would count that lab work (or the decision to perform the test) as additional workup planned.


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