# E/M MDM New problem "additional work up Planned"



## smagliocchetti (Feb 19, 2009)

Question: 

E/M MDM 
Type of Problem

New problem, no additional work up planned 
vs. 
New problem, additional work up planned

We know that x-rays or labs are considered " additional work up" does  a referral to a consultation requested by the primary care physician constitute additional work up ?   CMS and our local Medicare carrier do not clarify or define " additional workup".  Any information that can be provided would be greatly appreciated. Please state your references if applicable. 

Thank you, 
Sonia and Lorna CPC


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## RebeccaWoodward* (Feb 19, 2009)

You present a great question. This should receive many responses.

My opinion...“additional workup planned,” describes a problem that cannot be evaluated within the confines of the encounter. "Additional workup" is needed to help find a definitive diagnosis for that encounter. This could be a diagnostic study/plan...MRI, CT, PT, etc.

I verbally presented this question to our carrier and was informed that this type of "workup" was credited as such.

http://emuniversity.com/MedicalDecision-Making.html

"An example of a “new problem with no additional work-up planned” may be a new diagnosis of essential hypertension.  Examples of “new problem, with additional work-up planned” may include any new clinical issue which requires further investigation such as chest pain, proteinuria, anemia, shortness of breath, etc"

At the top of this link, there is a reference for other Medicare carriers


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## FTessaBartels (Feb 19, 2009)

*Request consult*

Yes, I would consider a decision to request a consultation as "additional work-up."

F Tessa Bartels, CPC, CEMC


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## smagliocchetti (Mar 4, 2009)

Thank you everyone. 

Sonia and Lorna


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## smagliocchetti (Mar 4, 2009)

Thank you everyone. 

Sonia and Lorna


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## jesusislord (Feb 20, 2012)

can face to face time be greater than counselling time in the e&m guidlines


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## KRivers26 (Mar 2, 2012)

Hi,
For Office and Outpatient Services, face-to-face time _is_ counseling time.  This includes the time the physician spends speaking with the patient regarding diagnostic results, surgical options, etc...    If this time exceeds more than 1/2 of the visit ,then the provider may bill on time.  In Inpatient Hospital, Hospital Observation, and Nursing Facility, the provider may bill on time based on unit/floor time. The same elements apply here as well, where if the unit/floor time exceeds more that 1/2 of the visit, the provider may bill on time. Unit/floor time is considered the time spent on the patients floor working on the patient's case.

Hope this helps!


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## Carrie Johnston (Aug 6, 2013)

*new problem*

new problem no additional work up planned. Starting a new script for the new problem is not additional work up right?


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## Lynda Wetter (Aug 6, 2013)

Carrie Johnston said:


> new problem no additional work up planned. Starting a new script for the new problem is not additional work up right?



No additional work up would be something that will have results. Like Labs for example.


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## eorthaus (Nov 5, 2018)

*Is referral to audiologist and ophthalmologist considered addtl work-up?*

Hello!
I am a new auditor and new member of AAPC.  Thank you in advance for your time and knowledge.  I'd like to ask a clarifying question to be able to audit more confidently.  Is a referral to audiologist and vision services for a new patient considered new problem with work-up?  I'm leaning towards yes, as hearing issues and vision issues would be addressed and diagnosed with these referrals, but would like to confirm with other AAPC members.  Thanks again!


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## AfzalShaik (Nov 13, 2018)

*Is referral to audiologist and ophthalmologist considered addtl work-up?*



eorthaus said:


> Hello!
> I am a new auditor and new member of AAPC.  Thank you in advance for your time and knowledge.  I'd like to ask a clarifying question to be able to audit more confidently.  Is a referral to audiologist and vision services for a new patient considered new problem with work-up?  I'm leaning towards yes, as hearing issues and vision issues would be addressed and diagnosed with these referrals, but would like to confirm with other AAPC members.  Thanks again!



Referrals are not consider as additional work. Additional work in the sense any lab,radiology,medicine was ordered, so referral can't be considered as additional workup

Regards,
SK.MD.AFZAL,CPC
Senior coder


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## thomas7331 (Nov 14, 2018)

afzal3193 said:


> Referrals are not consider as additional work. Additional work in the sense any lab,radiology,medicine was ordered, so referral can't be considered as additional workup



I'd say this is not completely correct.  Additional workup does usually refer to diagnostic testing, but in the context of MDM complexity, you should look at the reasoning behind a referral to know whether or not this should be considered additional workup. The CMS guidelines state that "decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem....  *The need to seek advice from others is another indicator of complexity of diagnostic or management problems*."  The fact that a patient is referred to another provider does not, in and of itself, constitute additional workup, but if the purpose of the referral is due to the provider needing input from a specialist to arrive at a definitive diagnosis would, in my opinion, be sufficient to count that problem as requiring additional workup.


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## eorthaus (Feb 2, 2019)

*Labs/Imaging Records Requested*

I have a clarifying question that I would love some insight on.  I always count ordering labs or imaging on a new patient as "a new problem with work-up".  I recently came across a couple notes during an audit where the physician did not order labs or imaging himself, but is requesting records of recent labs and imaging from the previous physician, with plans to order labs/imaging if these records are not received.  Would you still count this as "new problem with work-up"?  I am torn, and any guidance is much appreciated!!  The diagnoses related to the record requests are Essential HTN, Cerebral Infarction Hx, Hx of Post-hemorragic Anemia, Hx of Spine/pelvic Fx, and Hx of Femur Fx.


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