Weekly Tip-Scoring MDM ER Encounter

In this forum thread feel free to post your comments and areas for discussion that you may have based on the weekly auditing and compliance tips from NAMAS.

Moderators: Shannon DeConda, NAMAS Moderator

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saj402
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Joined: Thu Jul 25, 2013 11:16 am

Fri Feb 06, 2015 10:10 am

Hello, I am confused that this is not considered "with workup". The pt had labs and an EKG during the encounter. Isn't the patient being "worked up". Also under the management options pt had IV fluids so would that be considered Low?

And thank you for providing these scenarios!
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admin
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Mon Feb 09, 2015 10:14 am

Work-up means that after the encounter is finished, the patient has other services to do (homework) like go get an MRI, go off site for lab testing. Ultimately, the physician cannot render a decision/plan yet until that homework is complete. This is classified higher in terms of medical decision making than a patient who received diagnostic services onsite and a final plan had been created.
You are correct that IV fluids without additives is low risk, while IV fluids with additives is considered moderate risk.
saj402
Posts: 7
Joined: Thu Jul 25, 2013 11:16 am

Wed Feb 11, 2015 2:21 pm

Thank you for your explanation. However, may I add that the ED is a different setting than an office visit. In the Emergency Department, because of the readily availability of comprehensive diagnositc testing, assessments are frequently shortened to a single E/M encounter, with the work-up performed on the same day. According to the ACEP (American College of Emergency Physicians) - "It would make no sense to penalize an ED physician for efficiently assessing and managing the patient's presenting medical condition and assuring the work-up is performed in a timely manner." Based on resources such as ACEP our policy has been to allow ED providers credit of lab, xray, CTs as "additional workup". Thanks!
Shannon DeConda
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Mon Feb 23, 2015 9:09 pm

In the ER typically "additional work up" is considered to be an admission- would lead to a high majority of the encounters being counted as additional work up.
Remember that this is one of those areas that we have no definitive guidelines for. However, when we equate 4 points being applied for the need for additional work up- this would tend to show that the patient had some sort of high complexity which is threat to life or bodily function. This is how we would quantify the reasoning of the additional work up being considered as an admission.
Thank you,
Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN
Founder & President of NAMAS

Disclaimer: NAMAS cannot be held liable for any advice given that could have had a variable answer based on additional information.
lori
Posts: 45
Joined: Fri Aug 03, 2012 10:22 am

Tue Apr 07, 2015 3:22 pm

Hi, Shannon,
It seems like you touched on the idea that admission to the hospital equates to 'additional workup planned'. In the case of initial hospital care codes 99221-99223, sometimes a patient is admitted to the hospital but no diagnostics are ordered at the time of admission. Perhaps the H & P identifies a Plan of Care with various IV meds but no actual diagnostic tests. Does that still qualify as 'additional workup planned', based on the idea that the patient is being admitted and subsequent E/M evaluations are expected/planned (although not necessarily diagnostic tests)?

We also see this scenario in the case of a psychiatric hospital for codes 99221-99223. No true diagnostic tests are ordered but the patient is undergoing various therapies (therapeutic in nature but not diagnostic). Does that still qualify as 'additional workup planned', based on the fact the patient is being admitted and further E/M evaluations are expected/planned (but no diagnostic tests)?

Thank you for your help!
Shannon DeConda
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Wed Apr 08, 2015 12:20 pm

With an admission, the only code that requires High MDM (4 points for additional workup) would be the level 3 encounters. Keeping in mind that our guidance is that these patients should be those who requiring admission with a high severity problem- then we would expect that they will be undergoing additional orders for other testing, labs, etc... that would be that guidance. Otherwise if they were moderate severity they would be new problem without additional workup (3 points) and that would meet the documentation guideline as well.

Hope this helps.
Thank you,
Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN
Founder & President of NAMAS

Disclaimer: NAMAS cannot be held liable for any advice given that could have had a variable answer based on additional information.
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