# E/M Audit New Problem Additional Work-up



## jfries (Mar 8, 2011)

Does anyone have information pertaining to what is considered "additional work-up" to provide credit for this under the section Number of Diagnoses and Mangement Options? If you are aware of a website that I could use as a spceific point of research/information that would be great. Thank you, Julie Fries


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## btadlock1 (Mar 8, 2011)

This may help, but I'm not sure where it really came from:
Q. Is diagnostic testing the only thing that constitutes an additional workup in the number of diagnosis or management/treatment options (of the medical decision making section)?
A. No, additional workup includes any management/treatment options. The following are examples of “additional workup planned”. Documentation such as, “I recommend the patient begin physical therapy 3-4 times/week”, “change in prescription drugs”, “documenting that the patient needs IV fluids”, “smoking cessation discussed and patient given information and encouraged to attend” or  “advised patient to begin ROM exercises and demonstrated range of motion exercises.”
http://www.muhealth.org/documents/compliance/Word_Documents/Newsletters/March2005.doc


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## btadlock1 (Mar 8, 2011)

*This one's a little more reputable...*

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".

Date Posted: 10/16/2009, Date Revised: 11/24/2010

https://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#15


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## kviolette (Sep 17, 2014)

*Certified Med Coder*

I have wondered for a while if OXYGEN MONITOR and CARDIAC MONITOR in an inpatient setting are considered workups.  They contribute information in the provider's decision making.


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