Additional Work-up Planned
Any testing/consultation/referral that is being done beyond that
Encounter to assist the provider in medical decision making.
Encounter
Interaction between a covered member and a health care provider
for which evaluation and management service or other service(s) are
rendered and results in a claim submission
Questions and Answers
1 Q: When a separate written report for diagnostic tests/studies is prepared by the same individual performing the E/M service in an ER/ED place of service, should this be considered as a factor in the
E/M code selection?
A: No. Any specifically identifiable procedure reported separately from the E/M service should not
be considered in the selection of E/M service level reported. For example, a patient presents to the
ER/ED with chest pain and an EKG is performed. The EKG is normal; the attending provider
determines that the patient has angina and provides a prescription. This would NOT be considered
Additional Work-Up Planned because the test was performed and a diagnosis was made during the
ER/ED Encounter. If another provider other than the attending provider (such as a cardiologist or
radiologist) bills the CPT code for the interpretation, then 2 points are scored because the attending
provider is not billing for the interpretation separately.
2
Q: Will UnitedHealthcare require medical records for all reported E/M services?
A: No. UnitedHealthcare requests medical records when the data indicates a physician or other
health care professional has a billing pattern that deviates significantly from their peers.
3
Q: What if the Encounter doesn’t require Additional Work-up Planned but does require high
complexity medical decision making (MDM)?
A: The provider may submit medical records for review. Consideration will be given to the medical
record provided. The Additional Work-up is a component of the number of diagnoses and
management options. There are two other elements – amount/complexity of data and the table of
risk which contribute to the medical decision making element. CPT also notes that when counseling
and/or coordination of care dominates more than 50% of the encounter with the patient and/or family,
then time shall be considered the key or controlling factor to qualify for a particular level of E/M
services.
