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MDM questions

  1. #1
    Default MDM questions
    Medical Coding Books
    I just recently started coding ER encounters.

    I'd like to know what the ER coders out there are considering additional work-up for the presenting problem.

    I'm being told that you'll never get +4 pts on the presenting problem table. Is this true?


  2. #2
    Hi Daniel,

    Per the AAPC CEDC Practicum, additional workup in the ED does not include results available during the ED visit.

    Some examples of additional workup include a scheduled appointment or testing post ED documented by the ED provider, admission to inpatient or observation status and transfer to another facility or to the OR.

    There are organizations that assign additional workup planned when three or more ancillary studies or a special study (CT, MRI, US) are ordered.

    To answer your question about never getting 4+ points, I never say never. A patient presenting with a finger lac requiring sutures could experience Status Epilepticus resulting in an admission.

  3. #3
    Atlanta, GA
    Quote Originally Posted by Mojo View Post

    To answer your question about never getting 4+ points, I never say never. :
    I agree, dealing in absolutisms is looking for trouble in this field. Though I would say the majority of charts that I come across don't meet for the 4+ points there, we do come across a good number of charts with additional workup planned. Another example that I see somewhat regularly that Mojo didn't mention is the doctor scheduling a cardiac stress test.

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