# Medical Decision Making - additional work-up



## kte01a (Mar 17, 2009)

If a physician schedules major surgery to treat a new problem, identifying risk factors, etc, is this considered additional work-up (in the context of Medical Decision Making), giving 4 pts towards the number of diagnoses or management options?  I cannot find anything concrete as to how "additional work-up" is defined.


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## FTessaBartels (Mar 17, 2009)

*Not to me*

Scheduling surgery does not equal "additional work-up" to my way of thinking. 

Scheduling additional diagnostic procedures (e.g. colonoscopy to discover reason for blood in stool), requesting additional consultation, ordering additional tests are all examples of what I consider as "additional work-up."

F Tessa Bartels, CPC, CEMC


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## Lisa Bledsoe (Mar 17, 2009)

*Table of Risk*

I am in complete agreement with Tessa.  In this scenario it would appear that the work up has been done and decision for surgery made, which falls into the table of risk.


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## RebeccaWoodward* (Mar 17, 2009)

Agreed...this is how I utilize the audit tools, also


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## kte01a (Mar 18, 2009)

Sounds good.  Thanks all!


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