jllindell
New
What constitutes "additional work up" when addressing a new problem? Would any ancillary services count towards additional work up?
Jenell CPC, CPC-H
Jenell CPC, CPC-H
-
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Wiki MDM New Problem with additional work up
- Thread starter jllindell
- Start date
kris07
New
Yes- New Problem that requires additional testing be ordered to confirm diagnosis/condition
jllindell
New
If physician ordered a CT scan then would you:
Table A. count this as new problem with additional workup = 4
and
Table C review and/or oder of test in radiology section of CPT= 1
Table A. count this as new problem with additional workup = 4
and
Table C review and/or oder of test in radiology section of CPT= 1
Pam Warren
True Blue
Both. You have to consider the number of diagnostics and management options, the data ordered/reviewed and the risk involved, based on the provider's decision making for the presenting problem.
So if the patient presented with a new problem (cough x 4 weeks), was a long-time smoker and OTC cough meds were not working, so the physician ordered a CXR, you'd have a new problem w/workup, a data point for the radiology test, and under table of risk, you'd have a new problem with uncertain diagnosis. In this case, you'd have moderate MDM. In the table of risk, you'd go to the single highest level that most closely matches the scenario.
So if the patient presented with a new problem (cough x 4 weeks), was a long-time smoker and OTC cough meds were not working, so the physician ordered a CXR, you'd have a new problem w/workup, a data point for the radiology test, and under table of risk, you'd have a new problem with uncertain diagnosis. In this case, you'd have moderate MDM. In the table of risk, you'd go to the single highest level that most closely matches the scenario.