Additional work up

Hi,

In the ER when looking at the MDM and starting with number of diagnoses or treatment options I rarely give the Er providers the highest level of number of diagnosis or treatment options for a new problem because any work up is done within the ER visit.

I am looking for clarification. Does anyone have a reference that says to consider additional work up "planned" that the work up must be done at a future date and not on the same date within the same encounter. (the patient has not left the facliilty just went to x-ray then back to ER room)

THank You
Louise

re: Additional work up

The Documentation Guidelines don't give us examples, but I think most coders assume that the work up will be done after the provider has finished the visit. In the ED, that could be because the patient is going to be admitted, and have a cath done, or a stress test done in the a.m., or another diagnostic test or consult that won't be completed by the time the ED visit is over.