Wiki Does surgery=add'l work up planned

[SUEV]

When a patient is seen for the first time by the surgeon and they're diagnosed with a disease that requires surgery to treat it (i.e., appendicitis), would this be considered a new problem with additional work up planned? There will be pre-op labs done but the diagnosis is established at the end of the E/M.
Thank you for any opinions...

Sue

 

[Pam Warren]

No, since the decsion was made for surgery without any additional workup, I count the surgery under the table of risk and not as workup. If you order pre-op labs however, (the results of which can change the plan for surgery), I'd consider that additional workup.

 

[SUEV]

Pre-Op Labs

Thank you for responding Pam. Just to clarify-if the ER has already drawn the labs and the surgeon reviews them and decides to bring them to surgery, that would be a new problem without work-up planned. If the labs haven't been done yet and the surgeon decides to bring the pt to the OR and orders routine pre-op labs, that would be a new problem with work-up planned? This distinction is important since we have heard from other consultants that anytime the patient is brought to surgery, it's considered work-up planned. As you know, this can make the difference between moderate and high complexity for "emergency" surgeries. It seems odd to me that an otherwise healthy person who has acute appendicitis and needs to have surgery would have the same complexity of medical decision making as someone who has a possible perforated colon and requires an exploratory surgery. I've looked extensively for any articles, guidelines, etc. that define "work-up". There are some that state to give credit if there isn't a diagnosis at the end of the visit and the provider needs to do further investigation to diagnose the symptoms. Others just say "work-up" is any diagnostic test and don't clarify whether it only applies to undiagnosed conditions. I'd appreciate it if you could let me know of any references that you have found helpful in regards to this.
Thanks again,
Sue

 

[Pam Warren]

You're right in your post, as far as my understanding goes.When I audit, I consider 'workup planned' to be anything diagnostic in the lab, rad, or medicine section of CPT--bloodwork, imaging, PFTs, EKGs, etc. Workup is done to further investigate an ambiguous diagnosis when more info is needed. Most surgery and procedures are not workup---they're typically therapeutic, and usually done for a definitive reason.