Additional Work-up Planned

The Additional Work-Up Planned is a key element for a highly complex E/M service and constitutes any testing/consultation/referral that is being done beyond that Encounter to assist the provider in medical decision making. An example of Additional Work-Up Planned is when the provider of service contacts the patient’s physician or other specialist with recommendations for additional follow-up care and the discussion is documented in the medical records. A simple instruction to the patient to contact their primary physician does not constitute Additional Work-up Planned.

The examples below are based on a record review assessment and further illustrate the medical decision making component scoring above.

Office E/M documentation: 

(1) Established Problem- Worsening: An established patient sees his/her gastroenterologist due to worsening of his/her Crohn’s disease. The physician provides an E/M service and adjusts the patient’s medication. Two (2) points would be assigned for Established Problem- Worsening score. 

(2) New Problem-Additional Work-up planned: The patient presented to his/her new family practitioner with symptoms requiring additional tests and/or a referral to a specialist. In addition the family practitioner contacts the specialist directly to discuss the patient’s case. Four (4) points would be assigned for New Problem-Additional Work-up Planned score.  

 

Emergency Room/Department E/M documentation:

(1) New Problem- No Additional Work-up Planned: A patient presents with a low grade fever and pharyngitis. An examination is provided and the patient is sent home with a prescription and instructed to follow-up with their primary care physician as needed. Three (3) points would be assigned for New Problem- No Additional Work-up Planned score. 

(2) New Problem – Additional Work-up Planned: A patient presents with abdominal pain and hematuria. The ER/ED physician (or staff) schedules an outpatient MRI and/or communicates directly with the patient’s primary physician or other specialist after discharge from the ER/ED and the discussion has been documented in the medical record. Four (4) points for Additional Work-up Planned would be scored. Credit is not given for Additional Work-up Planned if the clinical testing/consultation occurred during the ER/ED Encounter or in the instance when the patient is instructed to contact their primary physician. This application is consistent with a more complex E/M code level. 

When it is determined the documentation does not support the E/M code reported, the E/M code will be denied and the provider may resubmit the claim with a revised E/M code.