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Thread: "Work up"

  1. #1

    Default "Work up"

    AAPC: Back to School
    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...

  2. #2
    Join Date
    Apr 2007
    Duluth, Minnesota


    just have to ask about your "nick", does it stand for:
    one fish
    two fish
    red fish
    blue fish

    i love it!
    Donna, CPC, CPC-H

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default 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

  4. #4


    Good Job! Ya gotta love Dr Seuss!

  5. #5


    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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