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MDM and "additional workup"

  1. #1
    Kansas City, MO
    Question MDM and "additional workup"
    Medical Coding Books
    What constitutes "additional work up planned" when considering for medical decision making?

    For has an enlarged lymph node, and dr wants blood ordering a lab test considered a "workup"?
    Ordering a CT or an Xray?

  2. #2
    North Carolina
    I find this area to vary by opinion.

    My opinion...additional workup takes place outside of that current encounter. Example...CT, MRI, referral to another provider, etc. I do not consider "in-house" labs/xrays (i.e.-chest xray) (MOST TIMES) to be considered additional workup. I can tell you that the last E/M workshop I attended, conducted by the AAPC, also shares this same concept.

  3. #3
    Kansas City, MO
    Thank you Rebecca. Ever do something a million times and then start questioning yourself?!

  4. #4
    Overland Park, KS
    I agree with Rebecca here. Additional workup would be any workup that would occur outside of that encounter, such as if the patient came in for recurring headaches and the provider sent the patient for a CAT scan. Ordering labs would not qualify here for additional workup.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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