Results 1 to 3 of 3

ER Medical Decision Making

  1. #1
    Default ER Medical Decision Making
    Medical Coding Books
    If the ER physician reviews lab or x-rays, does this justify counting the dx and management options as a new problem with additional workup even if no further treatment was ordered other than any labs or x-rays at the time the patient presents to the ER? Thanks for any help with this.

  2. #2
    Milwaukee WI
    Default My first instinct
    My first instinct is "no" ... or not necessarily. If the patient is just being sent home w/ Rx for whatever the problem is, then I definitely would NOT count this as a new problem w/ add'l workup.

    But if the patient is going to be referred to a specialist for follow-up, or is going to be admitted, then I might reconsider ... but NOT because of the labs / Xray, but because the referral to another physician would be the additional work-up.

    I'm open to hearing other points of view.

    F Tessa Bartels, CPC, CEMC

  3. Smile ER MDM opinion
    I agree.

    Add'l work up could be considered a consult while the pt is in the ED, being sent after ED visit to a specialist, needing FURTHER work-up (this being stated/written in the pt visit chart) w/ there private physician.

    Our group will allow the workup to be considered "additional" if it cannot be done in an office visit setting, you might want to check with your group on that one.

    hope this helps!

Similar Threads

  1. Medical Decision Making - with an oncologist
    By jhammond0128 in forum Auditing General Discussion
    Replies: 1
    Last Post: 04-10-2015, 04:03 PM
  2. Medical Decision Making - illness or injuries
    By midnightsun1369 in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 03-27-2015, 12:17 PM
  3. Help with E/M Medical Decision Making
    By jflynn in forum E/M
    Replies: 3
    Last Post: 11-17-2011, 09:05 PM
  4. Medical Decision Making
    By in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 02-16-2011, 11:34 AM
  5. Medical Decision Making - risk component
    By ARCPC9491 in forum E/M
    Replies: 31
    Last Post: 08-18-2008, 02:23 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.