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Re: New Problem additional workup

  1. Default Re: New Problem additional workup
    Medical Coding Books
    Often times the patient comes into the ER and tests are run, and then our surgeon admits the patient. Would the fact that he is admitting the patient be considered a new problem with an additional workup for the the admitting doctor or would it only be considered a new problem additional workup if he is the one that ordered the tests to dx the problem. I read an article that said that they always considered it be an additional workup for the admitting doctor.



  2. #2
    Milwaukee WI
    Default Who ordered the tests?
    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.

    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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