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 â€śadditional workup plannedâ€ť. Documentation such as, â€śI recommend the patient begin physical therapy 3-4 times/weekâ€ť, â€śchange in prescription drugsâ€ť, â€śdocumenting that the patient needs IV fluidsâ€ť, â€śsmoking cessation discussed and patient given information and encouraged to attendâ€ť or â€śadvised patient to begin ROM exercises and demonstrated range of motion exercises.â€ť
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