Who ordered the tests?
Let's say the patient shows up with RLQ pain, vomiting and anorexia x 1 day ..
ER doc calls surgeon for eval. Surgeon examines patient, suspects hot appendix, orders US and labs and once those results are in admits patient for appendectomy.
His evaluation and decision making required that additional work-up (labs, US) before a definitive decision was made, so I would consider this a new problem w/ work-up.
ON THE OTHER HAND ...
Let's say that the ER doc ordered the US and labs and when those results were in, called the surgeon to admit and performt he appy. The surgeon would have a new problem WITHOUT additional workup ...
Hope that helps.
F Tessa Bartels, CPC, CEMC
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