If you can determine from the documentation that the problem is new to the examiner, then credit for the new problem. Now as far as additional work up is concerned, I guess it depends on the location of service. If office, then any referrals to specialists or diagnostic tests ordered for subsequent encounters would be included in additional workup. It is a little different in the Emergency Department. Some folks only credit admissions and consultations from the ED as additional work up while others credit any additional tests needed to whittle down the differential diagnoses as additional workup.
I hope this helps.
-Maryann C. Palmeter, CPC
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