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Wiki Question on Additional Workup

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lydiasommerfigueroa@gmail.com

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An infectious disease physician is called in to consult at a hospital on an inpatient who has cellulitis. The hospitals usually take cultures on the patients as soon as they come in, and so a culture was taken two days before the date of the consult. The infectious disease physician diagnoses the cellulitis, but still needs the results of the culture, which will provide information needed in order for him to finalize his treatment: the organism, the organism’s sensitivities to antibiotics, and any resistance the organism may have to antibiotics.

My question is: the physician did not order the culture, but he does need this information to finalize his treatment plan. Does awaiting the culture results count as “additional workup” for this E/M service?
 
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Hello, I am not an expert but my thought is No, it is not a work up because MD is not ordering studies to determine what is happening with the pt. He already established Dx and needs to review the results for specificity. If it’s inpatient EM, I would give for Dx 3 points and for Data 1 for review but he needs to review at the time of service; otherwise, it’s zero.
 
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