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What constitutes "new problem with further work-up" for ED coding?

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Cathy Batten

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El Cajon, CA
Hello! Please help... What constitutes "new problem with further work-up" in the number of diagnosis or treatment options for ED E/M? This is 4 points versus "new problem with no work-up" which is 3 points". I have been told 2 different versions of how to code this.
 
If you do a little Google research you will find Todd Thomas is a highly respected ED Coding educator by ACEP. He defines "additional workup" by the ED provider as anything performed during the ED encounter to provide information either during or following the initial encounter. This would include admissions and transfers, diagnostics, consultation requests, etc.

Defer to your employer rules if they have more conservative rules and/or standards.
 
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