Work-up

Could you please describe what includes a work-up? I have a provider who reviewed a lab report the same day the lab was drawn, and considers that to be a work-up, and want 2 points from the audit I performed for the level of service. Is that correct?

I'm gonna say...

It depends. Was the lab ordered for routine monitoring as with a lipid panel or to evaluate a new problem like a fever or pain? The first is not a workup, the second is.

Work-up

The patient came to the ER, and the general surgeon was called, and he reviewed and dictated on the labs. The surgeon decides to admit the patient. Does this consitute 2 points?

Work-up

Additional work-up usually means "after the initial encounter". Further investigation is required.

work up

The Documentation Guidelines don't provide a lot of detail. You can download them and read them for yourself. They are posted on Codapedia, so just search Documentation Guidelines. They are attached to the article called, Documentation Guidelines.

For data points:
For lab, one point is given for reviewing or ordering one or 100 labs. If the MD personally reviews the image or tracing that someone else has or will interpret, then assign 2 points.

For the number of diagnosis addressed
The additional workup relates to whether you give the MD 3 or 4 points for number of diagnosis addressed, the MD gets 3 points for new problem, 4 for new problem with work up planned.

Your question is a bit confusing. Can you clarify which part of MDM you are discussing?