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Additional Workup Planned - Patient complained

  1. #1
    Default Additional Workup Planned - Patient complained
    Medical Coding Books
    Can someone please clarify if this scenario would be considered "additonal workup planned" for a new patient. Patient complained of something being stuck in throat so physician perfomed a fiber laryngoscopy in the office. I was taught, long ago, that yes you can count this & give it 4 points. If there are differing views, can you please suggest?

  2. #2
    Default Highmark Medicare Services
    This is how Highmark Medicare clarifies it:



    https://www.highmarkmedicareservices...rvices.html#18

    Question #18 below


    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".
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    Default
    I agree that this would be additional workup. A definitive diagnosis could not be made without the scope to determine if it was a FB, tumor, abscess...

    In the ED, we consider additional workup as an admission, transfer, going to the OR or further testing after the ED visit. If testing results are available before discharge, we do not consider it addtional.

  4. #4
    Default
    Here is another link to Highmark Medicare Services, I only advise that if your Medicare carrier IS Highmark Medicare to follow this link.

    https://www.highmarkmedicareservices...alization.html
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  5. #5
    Default
    Quote Originally Posted by misbell View Post
    Can someone please clarify if this scenario would be considered "additonal workup planned" for a new patient. Patient complained of something being stuck in throat so physician perfomed a fiber laryngoscopy in the office. I was taught, long ago, that yes you can count this & give it 4 points. If there are differing views, can you please suggest?
    Was the laryngoscopy done on the same day as the office visit and resulted?
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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