"Work up"

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Is there any documentation out there regarding what is defined as a "work up" in relation to "Number of diagnoses or Treatment Options" in the MDM? If we do an x-ray in our office or a urinalysis for a patient coming in with a new problem, should it be counted as extensive? Seems like I've heard a couple different interpretations of "work up". Just wondering...
 
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Additional work up

When decided whether to give 3 points (new problem,no additional work up) vs 4 points (new problem, additional work-up planned), I look at two words:
"additional" and "Planned."

So for your example ... say patient complains of burning on urination and you do a UA in the office. I'd give this 3 points - new problem, no additional workup planned

BUT ... if the doctor felt he should order an ultrasound of the bladder or some other test ... then I'd give 4 points - new problem, additional work-up planned

Just my opinion.

F Tessa Bartels, CPC, CPC-E/M
 

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Thanks! So, for a doctor's office, "add'l work up" would refer to requests for consultation or diagnostic testing outside the scope of what is done in my provider's office? Would that include x-rays performed and read in the office?
 
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