AAPC - Back to school
Results 1 to 4 of 4

Thread: E/M Audit New Problem Additional Work-up

  1. #1
    Join Date
    Apr 2007

    Default E/M Audit New Problem Additional Work-up

    AAPC: Back to School
    Does anyone have information pertaining to what is considered "additional work-up" to provide credit for this under the section Number of Diagnoses and Mangement Options? If you are aware of a website that I could use as a spceific point of research/information that would be great. Thank you, Julie Fries

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    This may help, but I'm not sure where it really came from:
    Q. Is diagnostic testing the only thing that constitutes an additional workup in the number of diagnosis or management/treatment options (of the medical decision making section)?
    A. No, additional workup includes any management/treatment options. The following are examples of “additional workup planned”. Documentation such as, “I recommend the patient begin physical therapy 3-4 times/week”, “change in prescription drugs”, “documenting that the patient needs IV fluids”, “smoking cessation discussed and patient given information and encouraged to attend” or “advised patient to begin ROM exercises and demonstrated range of motion exercises.”

  3. #3
    Join Date
    Apr 2007
    Lubbock, TX

    Talking This one's a little more reputable...

    18.What constitutes additional workup in the Amount and Complexity of Data grid for Medical Decision Making?

    The number of possible diagnosis and/or the number of management options that must be considered is based on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. For each encounter an assessment clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. Additional workup is defined as anything that is being done beyond that encounter at that time. For example, if a physician sees a patient in his office and needs to send that patient on for further testing, that would be additional workup. The physician needs to obtain more information for his medical decision making. For more information, please refer to The Medicare A/B Reference Manual, Chapter 23, "Evaluation and Management".

    Date Posted: 10/16/2009, Date Revised: 11/24/2010


  4. #4

    Default Certified Med Coder

    I have wondered for a while if OXYGEN MONITOR and CARDIAC MONITOR in an inpatient setting are considered workups. They contribute information in the provider's decision making.

Similar Threads

  1. New problem no additional workup
    By Tonyj in forum E/M
    Replies: 0
    Last Post: 07-24-2014, 01:19 PM
  2. MDM New Problem with additional work up
    By jllindell in forum E/M
    Replies: 3
    Last Post: 05-05-2014, 10:46 AM
  3. E/M MDM New problem "additional work up Planned"
    By smagliocchetti in forum Medical Coding General Discussion
    Replies: 8
    Last Post: 08-06-2013, 12:45 PM
  4. New problem with additional workup
    By snt314 in forum E/M
    Replies: 2
    Last Post: 05-23-2013, 09:53 AM
  5. ED:New Problem w or w/o additional work up
    By Jessheartz in forum E/M
    Replies: 2
    Last Post: 10-17-2012, 11:02 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.