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Add'l workup planned = further care ?

  1. #1
    Default Add'l workup planned = further care ?
    Medical Coding Books
    Does anyone use this interpretation when auditing for MDM? We had a patient seen in the ER for abdominal pain and after tests were reviewed by the surgeon, a diagnosis was made and it was determined she required surgery to take care of the problem. The tests were ordered by the ER, not the surgeon. A consultant told us because the patient was being taken to surgery it's considered add'l workup planned because further care is required. Therefore this would get 4 points. My understanding of workup was testing to determine what the problem is, not treatment for the problem. Is anyone familiar with this take on the issue?
    Sue Vermette, CPC, CPMA

  2. #2
    Milwaukee WI
    Default Additional work-up = diagnostic
    I interpret additional work-up to mean additional diagnostic work required. This MIGHT be a surgery (diagnostic lap for example).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    That's the way I think of it too-diagnostic as opposed to therapeutic. Thanks for the response.
    Sue Vermette, CPC, CPMA

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