# ER Medical Decision Making



## eeoo (May 11, 2009)

If the ER physician reviews lab or x-rays, does this justify counting the dx and management options as a new problem with additional workup even if no further treatment was ordered other than any labs or x-rays at the time the patient presents to the ER?  Thanks for any help with this.


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## FTessaBartels (May 11, 2009)

*My first instinct*

My first instinct is "no" ... or not necessarily. If the patient is just being sent home w/ Rx for whatever the problem is, then I definitely would NOT count this as a new problem w/ add'l workup.

But if the patient is going to be referred to a specialist for follow-up, or is going to be admitted, then I might reconsider  ... but NOT because of the labs / Xray, but because the referral to another physician would be the additional work-up.

I'm open to hearing other points of view.

F Tessa Bartels, CPC, CEMC


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## 808coder (May 11, 2009)

*ER MDM opinion*

I agree.  

Add'l work up could be considered a consult while the pt is in the ED, being sent after ED visit to a specialist, needing FURTHER work-up (this being stated/written in the pt visit chart) w/ there private physician.  

Our group will allow the workup to be considered "additional" if it cannot be done in an office visit setting, you might want to check with your group on that one.

hope this helps!


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