# Age old debate-what is considered further workup



## mssalemny (May 8, 2014)

Ok all my coder counterparts our there... I have a question which I am sure will get many different opinions..

What actually is considered "additional work-up" ?   

We are auditing for a large practice and they have the capability to do there "in-house" ua's , rapid streps and flu tests, etc. They also perform x-rays. I have my thought process with these tests that are ordered and completed, but being the information nerd that I am, I have been reading many different articles on the topic. So, what is everyone's opinion or take on what is considered additional work-up? 

Thanks.. I always appreciate my counterparts opinions.


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## MarcusM (May 8, 2014)

For me, everything that is done while the patient is in the office is part of the E&M with whatever procedure codes added for lab, x-rays, etc added as another line item with modifiers if necessary.  Once the patient leaves the office, and then if additional work or MDM is required or records review or whatever, that would seem to be additional workup.

https://www.aapc.com/memberarea/forums/showthread.php?t=91013 
posts: "As per Novitas Solutions, Inc Q/A section: 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."


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