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Planned Additional work up in E\M

Amy Posted Thu 24th of October, 2019 00:48:55 AM
What is the definition of Planned Additional work up. please clarify my below example. 1.Today provider ordered LABs for Anemia and that lab results got next day. can we consider this as additional work up?. 2. Today provider ordered LABs for Anemia and that lab results got same day. can we consider this as additional work up?. which we can consider additional workup in this two examples?
SuperCoder Answered Thu 24th of October, 2019 09:25:49 AM

Hi,

Thanks for your question.

 

Additional workup planned means that the provider after examining the patient orders for clinical lab or radiology tests.

 

In both the scenarios we will count them as additional work up planned since the provider ordered for lab tests. The results whether received same day or next day does not change the leveling of E/M for today’s DOS.

 

For example, while calculating for E/M level in MDM table.

 

If a patient presents with new problem to the provider and the provider after examination orders for lab tests then 4 points will be given to the patient in first table of MDM (Number of Diagnosis or Management Options) and 1 point for ‘Review and/or order of clinical lab tests’ in second table (Amount and/or Complexity of Data reviewed).

 

If a patient presents with established problem; worsening to the provider and the provider order or lab tests then 2 points will be given to the patient in first table of MDM (Number of Diagnosis or Management Options) and 1 point for ‘Review and/or order of clinical lab tests’ in second table (Amount and/or Complexity of Data reviewed).

 

Hope this helps.

Thanks.

Amy Posted Tue 29th of October, 2019 04:35:09 AM
thank you so much.
SuperCoder Answered Wed 30th of October, 2019 00:53:17 AM

Thank you, happy to help.

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