I am auditing a chart where the surgeon will not perform surgery until patient is cleared by cardiology. He referred the patient to a cardiologist for a pre-op consult. He wants consult done asap, so he can proceed with scheduling the surgery. Would MDM credit be given for "additional workup" (in Number of Diagnoses or Treatment Options section)?
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Wiki New problem with additional workup
- Thread starter snt314
- Start date
MikeEnos
Guest
This may be a case-by-case suggestion, but depending on the scenario couldn't the surgery itself be additional workup?
I do think this would be determined case-by-case. Novitas Solutions is the MAC for our jurisdiction and their FAQ states: 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. When the surgery is contributing to the medical decision making, then I think it could be additonal workup.