# Additional workup- MDM



## mcdream (Mar 7, 2019)

Hi all!
Quick question: If a provider refers a patient to a specialist is that considered 'additional workup' (4 points)?
I understand xrays, labs, medicine tests (anything diagnostic in nature) beyond the visit count as 'additional workup'... anything else?
I appreciate your time!


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## Bernadette10 (Mar 10, 2019)

*Additional workup*

Yes, referring a patient to a specialist is considered additional workup.
https://www.doctors-management.com/improve-your-em-coding-by-focusing-on-medical-decision-making/ 
"Additional workup would be any work (tests, labs, studies, specialist referrals) that are expected to occur outside the current visit. Procedures do not count as additional workup unless diagnostic in nature."

I also found this:
https://www.healthicity.com/blog/common-errors-in-e/m-audits-frequently-asked-questions-part-1 
Q4. What is considered additional workup planned for MDM?
A4. See below.

"The Marshfield Clinic scoring tool is a method for assessing the underpinning CPT and Medicare E/M Documentation Guidelines medical decision making criteria. Neither CPT nor Medicare specify additional workup planned be performed after the evaluation & management service. Certainly any additional workup planned needed for patient care should be performed as soon as practical.

In an office setting, the patient visits the practitioner, who may determine that more in-depth information, including diagnostic testing, is necessary. The patient may provide samples right then (same day) and/or arrange for testing (e.g., radiological services) to be performed on a later date, and a followup appointment scheduled to review the results and further delineate the diagnosis...  Sometimes a patient may fail to complete the additional testing and might not even keep the followup visit. Even so, the additional workup planned would still be counted because during the initial visit the physician considered multiple diagnoses, management options, and actually ordered additional testing to be done. 

In the emergency department, because of the ready availability of comprehensive diagnostic testing, assessments are frequently shortened to a single E/M encounter with the workup performed on the same day. It would make no sense to penalize an ED physician for efficiently assessing and managing the patient's presenting medical condition and assuring the workup is performed in a timely manner. With regard to medical decision making, the key concept and actual language from the Marshfield Clinic Scoring Tool is that additional workup was planned, not whether it was performed on the same day or a later date." 

"Novitas defines additional workup as anything that is being done beyond that encounter at that time. The physician needs to obtain more information for his medical decision making."

2. What constitutes additional workup in the Amount and Complexity of Data grid for Medical Decision Making?
The number of possible diagnoses and/or the number of management options considered is on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions made by the physician. For each encounter, you should document an assessment clinical impression or diagnosis. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
Additional workup is anything 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.

https://www.novitas-solutions.com/w...showHeader=false&_adf.ctrl-state=l0qhs4bk5_33 

So overall I would say if the additional testing or referral is ordered or done in order to get more info for medical decision making, it should be counted as additional workup, whether it's done on the same day as the initial visit or later.


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## thomas7331 (Mar 11, 2019)

I agree that if the purpose of the referral to a specialist is diagnostic, then this additional work-up.  If the provider has already diagnosed the problem, though, and is just referring for treatment, I would not count that as additional work-up.  For example, a PCP may diagnose a patient with a hernia and refer them to a surgeon for possible repair - I would not consider that work-up.


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