• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 30th Nov, 2021. The site will be offline from 8:30PM (MT) till 10:30 PM MT. We apologize for any inconvenience this may cause.

"Work up"

Inquisitor

Guest
Messages
31
Best answers
0
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...
 
Messages
4,456
Location
Milwaukee WI
Best answers
0
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
 

Inquisitor

Guest
Messages
31
Best answers
0
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?
 
Top